If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. I? ?
Cigna-HealthSpring CarePlan | 2016 List of Covered Drugs (Formulary)
This is a list of drugs that members can get in Cigna-HealthSpring CarePlan.
Cigna-HealthSpring CarePlan is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.
Benefits may change on January 1 of each year.
You can always check Cigna-HealthSpring CarePlan’s up-to-date List of Covered Drugs online at www.CarePlanTX.com.
Limitations and restrictions may apply. For more information, call Cigna-HealthSpring CarePlan Member Services or read the Cigna-HealthSpring CarePlan Member Handbook.
You can get this information for free in other formats, such as large print, braille, or audio. Call at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free.
You can get this information for free in other languages. Call 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. Usted puede obtener esta información en otros idiomas, en forma gratuita. Llame al 1-877-653-0327 (TTY: 7-1-1). La llamada es gratuita.
This formulary was updated on 10/26/2016. For more recent information or other questions, please contact Cigna-HealthSpring CarePlan at 1-877-653-0327 or, for TTY users, 7-1-1, 7 days a week, 8 a.m. to 8 p.m. Central Time, or visit www.CarePlanTX.com
HPMS Approved Formulary File Submission ID 16156, Version Number 18
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including HealthSpring Life & Health Insurance Company, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
H8423_16_34813i Approved 12272016 16_F_TXMMP_BL
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. II?
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.
1. What prescription drugs are on the List of Covered Drugs?(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Cigna-HealthSpring CarePlan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”
Cigna-HealthSpring CarePlan will cover all medically necessary drugs on the Drug List if:
your doctor or other prescriber says you need them to get better or stay healthy, and
you fill the prescription at a Cigna-HealthSpring CarePlan network pharmacy.
Cigna-HealthSpring CarePlan may have additional steps to access certain drugs (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website at www.CarePlanTX.com or call Member Services at 1-877-653-0327 (TTY: 7-1-1).
2. Does the Drug List ever change?
Yes. Cigna-HealthSpring CarePlan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:
a cheaper drug comes along that works as well as a drug on the Drug List now, or
we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
Decide to require or not require prior approval for a drug. (Prior approval is permission from Cigna-HealthSpring CarePlan before you can get a drug.)
Add or change the amount of a drug you can get (called “quantity limits”).
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. III ?
Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)
(For more information on these drug rules, see pages III IV)
We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.
You can always check Cigna-HealthSpring CarePlan’s up to date Drug List online at www.CarePlanTX.com. You can also call Member Services to check the current Drug List at 1-877-653-0327 (TTY: 7-1-1).
3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?
If you are taking a Medicare Part D drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will mail you a letter explaining the change and tell you the next steps to take to switch to a different drug.
4. What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you.
5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:
Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Cigna-HealthSpring CarePlan before you fill
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. IV?
your prescription. If you don’t get approval, Cigna-HealthSpring CarePlan may not cover the drug.
Quantity limits: Sometimes Cigna-HealthSpring CarePlan limits the amount of a drug you can get.
Step therapy: Sometimes Cigna-HealthSpring CarePlan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1-95. You can also get more information by visiting our web site at www.CarePlanTX.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.
You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.
If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Cigna-HealthSpring CarePlan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions.
6. How will you know if the drug you want has limitations or if there are requiredactions to take to get the drug?
The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”
7. What happens if we change our rules on how we cover some drugs? Forexample, if we add prior authorization (approval), quantity limits, and/or steptherapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. V?
ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.
8. How can you find a drug on the Drug List?
There are two ways to find a drug:
You can search alphabetically (if you know how to spell the drug), or
You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it in the section that begins on page 96. If you are not sure what category to look under, you should look for your drug in the Alphabetical Drug List section. This section has a list of all the drugs in this book. Turn to the page listed in the Alphabetical Drug List section and find the name of your drug in the first column of the list.
To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents That is where you will find drugs that treat heart conditions.
9. What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 1-877-653-0327 (TTY: 7-1-1) and ask about it. If you learn that Cigna-HealthSpring CarePlan will not cover the drug, you can do one of these things:
Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. VI ?
10. What if you are a new Cigna-HealthSpring CarePlan member and can’t find your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Cigna-HealthSpring CarePlan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.
We will cover a 30-day supply of your drug if:
you are taking a drug that is not on our Drug List, or
health plan rules do not let you get the amount ordered by your prescriber, or
the drug requires prior approval by Cigna-HealthSpring CarePlan, or
you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 98 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.
We will cover a temporary 30-day supply of your drug if an unexpected move happens. For example, if you are released from the hospital to go home or to a nursing home and you are not able to get your medicine.
11. Can you ask for an exception to cover your drug?
Yes. You can ask Cigna-HealthSpring CarePlan to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
For example, Cigna-HealthSpring CarePlan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.
Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. VII ?
12. How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.
13. How can you ask for an exception?
To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).
Cigna-HealthSpring CarePlan covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter.” Cigna-HealthSpring CarePlan covers some OTC drugs when they are written as prescriptions by your provider.
You can read the Cigna-HealthSpring CarePlan Drug List to see what OTC drugs are covered.
16. Does Cigna-HealthSpring CarePlan cover OTC non-drug products?
Cigna-HealthSpring CarePlan covers some OTC non-drug products when they are written as prescriptions by your provider.
You can read the Cigna-HealthSpring CarePlan Drug List to see what OTC non-drug products are covered.
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. VIII ?
17. What is your co-pay?
Cigna-HealthSpring CarePlan does not require a copay.
If you have any questions, call Member Services at 1-877-653-0327 (TTY: 7-1-1).
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. IX?
List of Covered Drugs
The list of covered drugs that begins on the next page gives you information about the drugs covered by Cigna-HealthSpring CarePlan. If you have trouble finding your drug in the list, turn to the Index that begins on page 96.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., ABILIFY) and generic drugs are listed in lower-case italics (e.g., alendronate).
The information in the necessary actions, restrictions, or limits on use column tells you if Cigna-HealthSpring CarePlan has any rules for covering your drug.
Abbreviation Explanation
B/D (Part B/Part D) This drug might be covered under Medicare Part B instead of Medicare Part D. More information might be needed for Cigna-HealthSpring CarePlan (MMP) to decide which plan should cover it.
MO (Mail Order) This drug is a maintenance medication available through mail order.
PA (Prior Authorization) This drug requires prior authorization.
QL (Quantity Limits) This drug has quantity limits.
ST (Step Therapy) This drug has step therapy requirements.
MC (Medicaid Covered) Non-Part D Drugs or OTC items that are covered by Medicaid
Note: The “MC” next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call
If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. X ?
Member Services at 1-877-653-0327 (TTY: 7-1-1). You can also read the Member Handbook to learn how to appeal a decision.
1 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
List of Drugs by Medical Condition
The drugs in this section are grouped into categories depending on the type of medical conditions they are
used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular
Agents. That is where you will find drugs that treat heart conditions.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
Analgesics (Drugs that Relieve Pain)
Analgesics
acephen $0(Tier 1) MC
acetaminophen tabs 325mg $0(Tier 1) MC
butalbital/acetaminophen/caffeine caps $0(Tier 1) QL (180 per 30 days) PA
butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg $0(Tier 1) QL (180 per 30 days) PA
butalbital/aspirin/caffeine $0(Tier 1) QL (180 per 30 days) PA
childrens mapap rapid tabs $0(Tier 1) MC
ed-apap $0(Tier 1) MC
esgic caps $0(Tier 1) QL (180 per 30 days) PA
gnp arthritis pain relief $0(Tier 1) MC
histaflex $0(Tier 1) MC
junior mapap $0(Tier 1) MC
mapap $0(Tier 1) MC
mapap acetaminophen extrastrength $0(Tier 1) MC
mapap arthritis pain $0(Tier 1) MC
mapap childrens $0(Tier 1) MC
mapap pm $0(Tier 1) MC
margesic $0(Tier 1) QL (180 per 30 days) PA
pain & fever $0(Tier 1) MC
pain & fever childrens $0(Tier 1) MC
pain & fever extra strength $0(Tier 1) MC
pain reliever pm extra strength $0(Tier 1) MC
q-pap $0(Tier 1) MC
q-pap childrens $0(Tier 1) MC
q-pap extra strength $0(Tier 1) MC
q-pap infants $0(Tier 1) MC
qc arthritis pain relief $0(Tier 1) MC
zebutal caps 325mg; 50mg; 40mg $0(Tier 1) QL (180 per 30 days) PA
Nonsteroidal Anti-inflammatory Drugs
all day pain relief $0(Tier 1) MC
all day relief $0(Tier 1) MC
aspirin ec tbec 325mg $0(Tier 1) MC
aspirin chew 81mg $0(Tier 1) MC
aspirin tabs 325mg $0(Tier 1) MC
aspirin tbec 325mg $0(Tier 1) MC
celecoxib caps $0(Tier 1) QL (60 per 30 days)
2 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
childrens ibuprofen susp 100mg/5ml $0(Tier 1) MC
childs ibuprofen $0(Tier 1) MC
congestion relief $0(Tier 1) MC
diclofenac potassium $0(Tier 1) MO
diclofenac sodium dr $0(Tier 1) MO
diclofenac sodium er $0(Tier 1) MO
diflunisal tabs $0(Tier 1) MO
effervescent pain relief $0(Tier 1) MC
enteric coated aspirin $0(Tier 1) MC
etodolac er $0(Tier 1) MO
etodolac caps $0(Tier 1) MO
etodolac tabs 400mg $0(Tier 1)
etodolac tabs 500mg $0(Tier 1) MO
fenoprofen calcium caps 400mg $0(Tier 1)
fenoprofen calcium tabs $0(Tier 1) MO
flurbiprofen tabs $0(Tier 1) MO
gnp ibuprofen junior strength $0(Tier 1) MC
gnp ibuprofen tabs $0(Tier 1) MC
ibu-200 $0(Tier 1) MC
ibu-drops $0(Tier 1) MC
ibu-drops infants $0(Tier 1) MC
ibuprofen childrens $0(Tier 1) MC
ibuprofen junior strength $0(Tier 1) MC
ibuprofen caps $0(Tier 1) MC
ibuprofen susp 100mg/5ml $0(Tier 1) MC
ibuprofen susp 100mg/5ml $0(Tier 1) MO
ibuprofen tabs 200mg $0(Tier 1) MC
ibuprofen tabs 400mg, 600mg, 800mg $0(Tier 1) MO
infants ibuprofen $0(Tier 1) MC
ketoprofen er $0(Tier 1) MO
ketoprofen caps $0(Tier 1) MO
meclofenamate sodium caps $0(Tier 1) MO
meloxicam tabs $0(Tier 1) MO
migraine formula $0(Tier 1) MC
nabumetone $0(Tier 1) MO
naproxen dr $0(Tier 1) MO
naproxen sodium tabs 275mg, 550mg $0(Tier 1) MO
naproxen susp, tabs $0(Tier 1) MO
oxaprozin $0(Tier 1) MO
piroxicam caps $0(Tier 1) MO
qc ibuprofen caps $0(Tier 1) MC
qc naproxen sodium $0(Tier 1) MC
3 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
salsalate $0(Tier 1)
sm ibuprofen tabs $0(Tier 1) MC
sulindac tabs $0(Tier 1) MO
tolmetin sodium $0(Tier 1) MO
Opioid Analgesics, Long-acting
DURAMORPH $0(Tier 2)
fentanyl $0(Tier 1) QL (15 per 30 days)
infumorph 200 $0(Tier 1)
infumorph 500 $0(Tier 1)
levorphanol tartrate tabs $0(Tier 1) QL (180 per 30 days)
methadone hcl intensol $0(Tier 1) QL (500 per 30 days)
METHADONE HCL INJ $0(Tier 2)
methadone hcl tabs $0(Tier 1) QL (360 per 30 days)
methadone hcl conc $0(Tier 1) QL (500 per 30 days)
methadone hcl oral soln 10mg/5ml $0(Tier 1) QL (2000 per 30 days)
methadone hcl oral soln 5mg/5ml $0(Tier 1) QL (4000 per 30 days)
morphine sulfate er tbcr $0(Tier 1) QL (90 per 30 days)
morphine sulfate inj 0.5mg/ml, 1mg/ml $0(Tier 1)
oxymorphone hydrochloride er $0(Tier 1) QL (60 per 30 days)
tramadol hcl er tb24 $0(Tier 1) QL (30 per 30 days)
XARTEMIS XR $0(Tier 2) QL (120 per 30 days)
Opioid Analgesics, Short-acting
acetaminophen/caffeine/dihydrocodeine $0(Tier 1) QL (360 per 30 days)
acetaminophen/codeine #2 $0(Tier 1) QL (360 per 30 days)
acetaminophen/codeine #3 $0(Tier 1) QL (360 per 30 days)
acetaminophen/codeine #4 $0(Tier 1) QL (240 per 30 days)
acetaminophen/codeine phosphate tabs 300mg; 60mg $0(Tier 1) QL (240 per 30 days)
acetaminophen/codeine soln $0(Tier 1) QL (5000 per 30 days)
acetaminophen/codeine tabs 300mg; 60mg $0(Tier 1) QL (240 per 30 days)
acetaminophen/codeine tabs 300mg; 15mg $0(Tier 1) QL (360 per 30 days)
ascomp/codeine $0(Tier 1) QL (180 per 30 days) PA
butalbital/acetaminophen/caffeine/codeine $0(Tier 1) QL (180 per 30 days) PA
butalbital/aspirin/caffeine/codeine $0(Tier 1) QL (180 per 30 days) PA
butorphanol tartrate inj $0(Tier 1)
butorphanol tartrate nasal soln $0(Tier 1) QL (6 per 30 days)
endocet $0(Tier 1) QL (360 per 30 days)
fentanyl citrate oral transmucosal $0(Tier 1) QL (120 per 30 days) PA
fentanyl citrate inj 100mcg/2ml $0(Tier 1) B/D
hydrocodone bitartrate/acetaminophen soln 325mg/15ml;
7.5mg/15ml
$0(Tier 1) QL (5400 per 30 days)
hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg $0(Tier 1) QL (360 per 30 days)
4 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg,
300mg; 5mg, 300mg; 7.5mg
$0(Tier 1) QL (390 per 30 days)
hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg,
325mg; 7.5mg
$0(Tier 1) QL (360 per 30 days)
hydrocodone/ibuprofen $0(Tier 1) QL (150 per 30 days)
hydromorphone hcl dosette $0(Tier 1)
hydromorphone hcl liqd $0(Tier 1) QL (1200 per 30 days)
hydromorphone hcl tabs $0(Tier 1) QL (240 per 30 days)
hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml $0(Tier 1)
ibudone tabs 5mg; 200mg $0(Tier 1) QL (150 per 30 days)
LAZANDA $0(Tier 2) QL (44 per 28 days) PA
lorcet $0(Tier 1) QL (360 per 30 days)
lorcet hd $0(Tier 1) QL (360 per 30 days)
lorcet plus tabs 325mg; 7.5mg $0(Tier 1) QL (360 per 30 days)
lortab tabs $0(Tier 1) QL (360 per 30 days)
morphine sulfate add-vantage $0(Tier 1)
morphine sulfate inj 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml,
25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml
$0(Tier 1)
morphine sulfate oral soln 20mg/5ml $0(Tier 1) QL (2700 per 30 days)
morphine sulfate oral soln 100mg/5ml $0(Tier 1) QL (540 per 30 days)
morphine sulfate oral soln 10mg/5ml $0(Tier 1) QL (5400 per 30 days)
MORPHINE SULFATE TABS 15MG, 30MG $0(Tier 2) QL (360 per 30 days)
nalbuphine hcl inj $0(Tier 1)
oxycodone hcl soln $0(Tier 1) QL (1200 per 30 days)
oxycodone hcl caps, tabs $0(Tier 1) QL (240 per 30 days)
oxycodone hcl conc $0(Tier 1) QL (360 per 30 days)
oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg,
325mg; 5mg, 325mg; 7.5mg
$0(Tier 1) QL (360 per 30 days)
oxycodone/aspirin $0(Tier 1) QL (360 per 30 days)
oxycodone/ibuprofen $0(Tier 1) QL (150 per 30 days)
reprexain tabs 10mg; 200mg $0(Tier 1) QL (150 per 30 days)
roxicet tabs $0(Tier 1) QL (360 per 30 days)
TALWIN $0(Tier 2)
tramadol hcl tabs $0(Tier 1) QL (240 per 30 days)
tramadol hydrochloride/acetaminophen $0(Tier 1) QL (240 per 30 days)
trezix caps 320.5mg; 30mg; 16mg $0(Tier 1) QL (360 per 30 days)
vicodin es tabs 300mg; 7.5mg $0(Tier 1) QL (390 per 30 days)
vicodin hp tabs 300mg; 10mg $0(Tier 1) QL (390 per 30 days)
vicodin tabs 300mg; 5mg $0(Tier 1) QL (390 per 30 days)
xylon $0(Tier 1) QL (150 per 30 days)
Anesthetics (Drugs that Decrease Feeling and Awareness)
Local Anesthetics
5 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
glydo $0(Tier 1)
lidocaine hcl jelly $0(Tier 1)
lidocaine hcl viscous $0(Tier 1)
lidocaine hcl gel 2% $0(Tier 1)
lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% $0(Tier 1)
lidocaine hcl external soln 4% $0(Tier 1)
lidocaine hcl mouth/throat soln 4% $0(Tier 1)
lidocaine viscous $0(Tier 1)
lidocaine/prilocaine crea $0(Tier 1)
lidocaine oint 5% $0(Tier 1)
lidocaine ptch 5% $0(Tier 1) QL (90 per 30 days) PA
premium lidocaine $0(Tier 1)
sore throat & cough lozenges $0(Tier 1) MC
Anti-Addiction/Substance Abuse Treatment Agents (Drugs that Treat Addiction Problems)
Alcohol Deterrents/Anti-craving
acamprosate calcium dr $0(Tier 1) PA
disulfiram tabs 250mg $0(Tier 1)
disulfiram tabs 500mg $0(Tier 1) MO
Opioid Dependence Treatments
buprenorphine hcl/naloxone hcl $0(Tier 1) QL (90 per 30 days) PA
buprenorphine hcl inj $0(Tier 1)
buprenorphine hcl subl $0(Tier 1) QL (90 per 30 days) PA
naltrexone hcl tabs $0(Tier 1) PA
SUBOXONE $0(Tier 2) QL (90 per 30 days) PA
Opioid Reversal Agents
naloxone hcl inj 0.4mg/ml, 2mg/2ml $0(Tier 1)
NARCAN $0(Tier 2) QL (4 per 30 days)
Smoking Cessation Agents
buproban $0(Tier 1) QL (60 per 30 days) MO
bupropion hcl sr tb12 150mg $0(Tier 1) QL (60 per 30 days) MO
CHANTIX CONTINUING MONTH PAK $0(Tier 2) QL (336 per 365 days)
CHANTIX STARTING MONTH PAK $0(Tier 2) QL (106 per 365 days)
CHANTIX TABS 0.5MG, 1MG $0(Tier 2) QL (336 per 365 days)
NICODERM CQ $0(Tier 1) MC
nicorelief $0(Tier 1) MC
NICORETTE $0(Tier 1) MC
NICORETTE MINI $0(Tier 1) MC
NICORETTE STARTER KIT $0(Tier 1) MC
nicotine polacrilex gum, lozg $0(Tier 1) MC
nicotine transdermal system $0(Tier 1) MC
nicotine transdermal system step 1 $0(Tier 1) MC
nicotine transdermal system step 2 $0(Tier 1) MC
6 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
nicotine transdermal system step 3 $0(Tier 1) MC
NICOTROL INHALER $0(Tier 2) QL (504 per 30 days) PA
NICOTROL NS $0(Tier 2) QL (40 per 30 days)
Antibacterials (Drugs that Treat Infection from Bacteria)
Aminoglycosides
amikacin sulfate inj $0(Tier 1)
gentak $0(Tier 1)
gentamicin sulfate pediatric $0(Tier 1)
gentamicin sulfate/0.9% sodium chloride $0(Tier 1)
gentamicin sulfate crea, inj, external oint, ophthalmic oint,
ophthalmic soln
$0(Tier 1)
isotonic gentamicin inj 0.8mg/ml; 0.9% $0(Tier 1)
neomycin sulfate $0(Tier 1)
neomycin/polymyxin b sulfates $0(Tier 1)
paromomycin sulfate $0(Tier 1)
streptomycin sulfate inj $0(Tier 1)
tobramycin sulfate ophthalmic soln $0(Tier 1)
tobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml, 80mg/2ml $0(Tier 1)
TOBREX OINT $0(Tier 2)
ZYLET $0(Tier 2)
Antibacterials, Other
ak-poly-bac $0(Tier 1)
alcohol prep pads $0(Tier 1)
baciim $0(Tier 1)
bacitracin zinc oint $0(Tier 1) MC
bacitracin/neomycin/polymyxin oint $0(Tier 1) MC
bacitracin/polymyxin b $0(Tier 1)
bacitracin inj, ophthalmic oint $0(Tier 1)
bacitracin external oint $0(Tier 1) MC
BACTROBAN NASAL $0(Tier 2)
chloramphenicol sodium succinate $0(Tier 1)
clindacin etz pledgets $0(Tier 1)
clindacin-p $0(Tier 1)
clindamax $0(Tier 1)
clindamycin hcl caps $0(Tier 1)
clindamycin phosphate add-vantage inj 900mg/6ml $0(Tier 1)
clindamycin phosphate in d5w $0(Tier 1)
clindamycin phosphate pharmacy bulk package $0(Tier 1)
clindamycin phosphate crea, gel, lotn, external soln, swab $0(Tier 1)
clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml,
900mg/6ml
$0(Tier 1)
colistimethate sodium $0(Tier 1)
7 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
CUBICIN $0(Tier 2) B/D
daptomycin $0(Tier 1) B/D
lansoprazole/amoxicillin/clarithromycin $0(Tier 1)
LINCOCIN $0(Tier 2)
lincomycin hcl inj $0(Tier 1)
linezolid susr, tabs $0(Tier 1) PA
linezolid inj 600mg/300ml $0(Tier 1) PA
methenamine hippurate $0(Tier 1)
metronidazole in nacl 0.79% $0(Tier 1)
metronidazole vaginal $0(Tier 1)
metronidazole crea, gel, inj, lotn, tabs $0(Tier 1)
mupirocin calcium $0(Tier 1)
mupirocin crea, oint $0(Tier 1)
neo-polycin $0(Tier 1)
neo-polycin hc $0(Tier 1)
neomycin/bacitracin/polymyxin $0(Tier 1)
neomycin/polymyxin/bacitracin zinc $0(Tier 1)
neomycin/polymyxin/bacitracin/hydrocortisone $0(Tier 1)
neomycin/polymyxin/gramicidin $0(Tier 1)
neomycin/polymyxin/hydrocortisone ophthalmic susp 1%;
3.5mg/ml; 10000unit/ml
$0(Tier 1)
nitrofurantoin macrocrystals caps 100mg, 50mg $0(Tier 1) QL (90 per 365 days)
nitrofurantoin monohydrate $0(Tier 1) QL (90 per 365 days)
nitrofurantoin monohydrate/macrocrystals $0(Tier 1) QL (90 per 365 days)
nitrofurantoin susp $0(Tier 1)
NORITATE $0(Tier 2)
polycin $0(Tier 1)
polymyxin b sulfate/trimethoprim sulfate $0(Tier 1)
polymyxin b sulfate inj $0(Tier 1)
povidone-iodine oint, soln $0(Tier 1) MC
PRIMSOL $0(Tier 2)
rosadan $0(Tier 1)
silver sulfadiazine crea $0(Tier 1)
SSD $0(Tier 2)
SYNERCID $0(Tier 2)
trimethoprim sulfate/polymyxin b sulfate $0(Tier 1)
trimethoprim tabs $0(Tier 1)
triple antibiotic plus oint 500unit/gm; 5mg/gm; 10000unit/gm;
10mg/gm
$0(Tier 1) MC
triple antibiotic oint $0(Tier 1) MC
TYGACIL $0(Tier 2)
vancomycin $0(Tier 1)
8 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
vancomycin hcl in dextrose $0(Tier 1)
vancomycin hcl caps 125mg $0(Tier 1) QL (40 per 10 days)
vancomycin hcl caps 250mg $0(Tier 1) QL (80 per 10 days)
vancomycin hcl inj $0(Tier 1)
vandazole $0(Tier 1)
XIFAXAN TABS 550MG $0(Tier 2) QL (60 per 30 days) PA
XIFAXAN TABS 200MG $0(Tier 2) QL (9 per 30 days) PA
ZYVOX SUSR $0(Tier 2) PA
Beta-lactam, Cephalosporins
cefaclor $0(Tier 1)
cefaclor er $0(Tier 1)
cefadroxil $0(Tier 1)
CEFAZOLIN $0(Tier 2)
CEFAZOLIN SODIUM/DEXTROSE INJ 2GM; 3% $0(Tier 2)
cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg $0(Tier 1)
cefdinir $0(Tier 1)
cefepime $0(Tier 1)
cefepime/dextrose $0(Tier 1)
cefixime $0(Tier 1)
cefotaxime sodium inj 1gm, 2gm, 500mg $0(Tier 1)
cefoxitin sodium inj 10gm, 1gm, 2gm $0(Tier 1)
cefpodoxime proxetil $0(Tier 1)
cefprozil $0(Tier 1)
ceftazidime $0(Tier 1)
CEFTAZIDIME/DEXTROSE $0(Tier 2)
ceftriaxone in iso-osmotic dextrose $0(Tier 1)
ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg $0(Tier 1)
cefuroxime axetil $0(Tier 1)
cefuroxime sodium inj 1.5gm, 7.5gm, 750mg, 75gm $0(Tier 1)
cephalexin caps 250mg, 500mg $0(Tier 1)
cephalexin susr, tabs $0(Tier 1)
SUPRAX SUSR 500MG/5ML $0(Tier 2)
tazicef inj 1gm, 2gm, 6gm $0(Tier 1)
TEFLARO $0(Tier 2)
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE $0(Tier 2)
aztreonam $0(Tier 1)
cefotetan $0(Tier 1)
imipenem/cilastatin $0(Tier 1)
INVANZ $0(Tier 2)
meropenem $0(Tier 1)
meropenem/sodium chloride $0(Tier 1)
9 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
Beta-lactam, Penicillins
amoxicillin $0(Tier 1)
amoxicillin/clavulanate potassium $0(Tier 1)
amoxicillin/clavulanate potassium er $0(Tier 1)
ampicillin $0(Tier 1)
ampicillin sodium inj $0(Tier 1)
ampicillin-sulbactam $0(Tier 1)
AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML $0(Tier 2)
BICILLIN L-A $0(Tier 2)
dicloxacillin sodium $0(Tier 1)
nafcillin sodium $0(Tier 1)
oxacillin sodium $0(Tier 1)
penicillin g potassium inj 20000000unit, 5000000unit $0(Tier 1)
penicillin v potassium $0(Tier 1)
PFIZERPEN-G $0(Tier 2)
piperacillin sodium/ tazobactam sodium $0(Tier 1)
piperacillin sodium/tazobactam sodium $0(Tier 1)
piperacillin/tazobactam $0(Tier 1)
TIMENTIN $0(Tier 2)
ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%;
3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML;
0.5GM/100ML
$0(Tier 2)
Macrolides
AZASITE $0(Tier 2)
azithromycin inj $0(Tier 1)
azithromycin tabs $0(Tier 1) QL (12 per 28 days)
azithromycin pack $0(Tier 1) QL (3 per 30 days)
azithromycin susr 100mg/5ml $0(Tier 1) QL (150 per 30 days)
azithromycin susr 200mg/5ml $0(Tier 1) QL (75 per 30 days)
clarithromycin er $0(Tier 1) QL (60 per 30 days)
clarithromycin susr, tabs $0(Tier 1)
e.e.s. 400 $0(Tier 1)
E.E.S. GRANULES $0(Tier 2)
ery $0(Tier 1)
ERY-TAB $0(Tier 2)
ERYPED 200 $0(Tier 2)
ERYPED 400 $0(Tier 2)
ERYTHROCIN LACTOBIONATE $0(Tier 2)
erythrocin stearate $0(Tier 1)
erythromycin base $0(Tier 1)
erythromycin ethylsuccinate susr, tabs $0(Tier 1)
erythromycin gel, oint, pads, soln $0(Tier 1)
10 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
ilotycin $0(Tier 1)
KETEK $0(Tier 2) QL (20 per 30 days)
ZMAX $0(Tier 2) QL (60 per 30 days)
Quinolones
AVELOX INJ $0(Tier 2)
BESIVANCE $0(Tier 2)
CILOXAN OINT $0(Tier 2)
CIPRO HC $0(Tier 2)
CIPRODEX $0(Tier 2)
ciprofloxacin er $0(Tier 1)
ciprofloxacin hcl soln, tabs $0(Tier 1)
ciprofloxacin i.v.-in d5w $0(Tier 1)
ciprofloxacin susr $0(Tier 1)
ciprofloxacin inj 400mg/40ml $0(Tier 1)
levofloxacin in d5w $0(Tier 1)
levofloxacin inj, oral soln, tabs $0(Tier 1)
MOXEZA $0(Tier 2)
moxifloxacin hcl $0(Tier 1)
ofloxacin $0(Tier 1)
VIGAMOX $0(Tier 2)
Sulfonamides
BLEPHAMIDE $0(Tier 2)
BLEPHAMIDE S.O.P. $0(Tier 2)
sodium sulfacetamide soln $0(Tier 1)
sulfacetamide sodium/prednisolone sodium phosphate $0(Tier 1)
sulfacetamide sodium soln, susp $0(Tier 1)
sulfadiazine tabs $0(Tier 1)
sulfamethoxazole/trimethoprim $0(Tier 1)
sulfamethoxazole/trimethoprim ds $0(Tier 1)
sulfatrim pediatric $0(Tier 1)
Tetracyclines
demeclocycline hcl $0(Tier 1)
doxy 100 $0(Tier 1)
doxycycline hyclate caps, inj, tabs $0(Tier 1)
doxycycline monohydrate caps, tabs $0(Tier 1)
doxycycline caps 75mg $0(Tier 1)
doxycycline susr $0(Tier 1)
minocycline hcl caps, tabs $0(Tier 1)
mondoxyne nl $0(Tier 1)
morgidox 1x100mg caps $0(Tier 1)
morgidox 1x50mg $0(Tier 1)
morgidox 2x100mg caps $0(Tier 1)
11 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
tetracycline hcl caps $0(Tier 1)
Anticonvulsants (Drugs that Control Seizures)
Anticonvulsants, Other
APTIOM TABS 200MG, 400MG, 800MG $0(Tier 2) QL (30 per 30 days) MO
APTIOM TABS 600MG $0(Tier 2) QL (60 per 30 days) MO
BRIVIACT ORAL SOLN $0(Tier 2) QL (1200 per 30 days)
BRIVIACT INJ $0(Tier 2) QL (600 per 30 days)
BRIVIACT TABS 100MG $0(Tier 2) QL (120 per 30 days)
BRIVIACT TABS 10MG, 25MG, 50MG, 75MG $0(Tier 2) QL (60 per 30 days)
FYCOMPA $0(Tier 2) MO
levetiracetam er $0(Tier 1)
levetiracetam inj, oral soln $0(Tier 1)
levetiracetam tabs $0(Tier 1) MO
POTIGA $0(Tier 2) QL (90 per 30 days) PA
MO
roweepra $0(Tier 1) MO
SPRITAM TB3D 750MG $0(Tier 2) QL (120 per 30 days)
SPRITAM TB3D 1000MG, 250MG, 500MG $0(Tier 2) QL (60 per 30 days)
Calcium Channel Modifying Agents
CELONTIN $0(Tier 2) MO
ethosuximide $0(Tier 1) MO
LYRICA SOLN $0(Tier 2) QL (900 per 30 days)
LYRICA CAPS 225MG, 300MG $0(Tier 2) QL (60 per 30 days) MO
LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG,
75MG
$0(Tier 2) QL (90 per 30 days) MO
zonisamide $0(Tier 1) MO
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg $0(Tier 1) QL (150 per 30 days)
clonazepam odt tbdp 2mg $0(Tier 1) QL (300 per 30 days)
clonazepam tabs 0.5mg, 1mg $0(Tier 1) QL (150 per 30 days)
clonazepam tabs 2mg $0(Tier 1) QL (300 per 30 days)
DIAZEPAM GEL 10MG, 2.5MG, 20MG $0(Tier 2)
divalproex sodium $0(Tier 1) MO
divalproex sodium dr $0(Tier 1) MO
divalproex sodium er $0(Tier 1) MO
gabapentin caps, soln, tabs $0(Tier 1) MO
GABITRIL TABS 12MG $0(Tier 2) QL (120 per 30 days)
GABITRIL TABS 16MG $0(Tier 2) QL (90 per 30 days)
ONFI SUSP $0(Tier 2) QL (480 per 30 days)
ONFI TABS 20MG $0(Tier 2) QL (120 per 30 days)
ONFI TABS 10MG $0(Tier 2) QL (60 per 30 days)
phenobarbital $0(Tier 1) MO
12 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
primidone tabs $0(Tier 1) MO
SABRIL TABS $0(Tier 2) QL (180 per 30 days) PA
MO
SABRIL PACK $0(Tier 2) QL (200 per 30 days) PA
MO
tiagabine hydrochloride tabs 4mg $0(Tier 1) MO
tiagabine hydrochloride tabs 2mg $0(Tier 1) QL (240 per 30 days) MO
valproate sodium inj $0(Tier 1)
valproic acid caps, syrp $0(Tier 1) MO
Glutamate Reducing Agents
felbamate $0(Tier 1) MO
lamotrigine er $0(Tier 1) MO
lamotrigine odt $0(Tier 1)
lamotrigine chew, tabs $0(Tier 1) MO
topiramate cpsp, tabs $0(Tier 1) MO
TROKENDI XR CP24 100MG, 25MG, 50MG $0(Tier 2) QL (30 per 30 days)
TROKENDI XR CP24 200MG $0(Tier 2) QL (60 per 30 days)
Sodium Channel Agents
BANZEL $0(Tier 2) PA MO
carbamazepine er cp12 $0(Tier 1)
carbamazepine er tb12 100mg $0(Tier 1)
carbamazepine er tb12 200mg, 400mg $0(Tier 1) MO
carbamazepine chew, susp, tabs $0(Tier 1) MO
DILANTIN CAPS 30MG $0(Tier 2) MO
epitol $0(Tier 1)
fosphenytoin sodium $0(Tier 1)
oxcarbazepine susp $0(Tier 1)
oxcarbazepine tabs $0(Tier 1) MO
PEGANONE $0(Tier 2) MO
phenytoin infatabs $0(Tier 1) MO
phenytoin sodium extended $0(Tier 1) MO
phenytoin sodium inj $0(Tier 1)
phenytoin chew, susp $0(Tier 1) MO
TEGRETOL-XR TB12 100MG $0(Tier 2) MO
VIMPAT INJ $0(Tier 2) QL (1200 per 30 days)
VIMPAT ORAL SOLN $0(Tier 2) QL (1200 per 30 days)
MO
VIMPAT TABS $0(Tier 2) QL (60 per 30 days) MO
Antidementia Agents (Drugs that Help with Memory Loss)
Antidementia Agents, Other
ergoloid mesylates tabs $0(Tier 1) PA
NAMZARIC $0(Tier 2) QL (30 per 30 days)
13 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
Cholinesterase Inhibitors
donepezil hcl tabs 23mg, 5mg $0(Tier 1) QL (30 per 30 days) MO
donepezil hcl tabs 10mg $0(Tier 1) QL (60 per 30 days) MO
donepezil hcl tbdp 5mg $0(Tier 1) QL (30 per 30 days) MO
donepezil hcl tbdp 10mg $0(Tier 1) QL (60 per 30 days) MO
EXELON PT24 $0(Tier 2) QL (30 per 30 days) MO
galantamine hydrobromide soln $0(Tier 1) QL (200 per 30 days)
galantamine hydrobromide cp24 $0(Tier 1) QL (30 per 30 days) MO
galantamine hydrobromide tabs $0(Tier 1) QL (60 per 30 days) MO
rivastigmine tartrate $0(Tier 1) QL (60 per 30 days) MO
rivastigmine transdermal system $0(Tier 1) QL (30 per 30 days)
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl titration pak $0(Tier 1) QL (49 per 28 days)
memantine hcl tabs 10mg $0(Tier 1) QL (60 per 30 days)
memantine hcl tabs 5mg $0(Tier 1) QL (90 per 30 days)
memantine hydrochloride soln $0(Tier 1) QL (300 per 30 days)
NAMENDA TITRATION PAK $0(Tier 2) QL (49 per 28 days) MO
NAMENDA XR $0(Tier 2) QL (30 per 30 days) MO
NAMENDA XR TITRATION PACK $0(Tier 2) QL (28 per 28 days) MO
NAMENDA SOLN $0(Tier 2) QL (300 per 30 days) MO
NAMENDA TABS 10MG $0(Tier 2) QL (60 per 30 days) MO
NAMENDA TABS 5MG $0(Tier 2) QL (90 per 30 days) MO
Antidepressants (Drugs that Help with a Depressed Mood)
Antidepressants, Other
BRINTELLIX $0(Tier 2) QL (30 per 30 days) ST
MO
bupropion hcl er tb12 100mg, 200mg $0(Tier 1) QL (60 per 30 days) MO
bupropion hcl er tb12 150mg $0(Tier 1) QL (90 per 30 days) MO
bupropion hcl sr tb12 100mg, 200mg $0(Tier 1) QL (60 per 30 days) MO
bupropion hcl sr tb12 150mg $0(Tier 1) QL (90 per 30 days) MO
bupropion hcl xl tb24 300mg $0(Tier 1) QL (30 per 30 days) MO
bupropion hcl xl tb24 150mg $0(Tier 1) QL (90 per 30 days) MO
bupropion hcl tabs $0(Tier 1) MO
maprotiline hcl $0(Tier 1) MO
mirtazapine $0(Tier 1) QL (30 per 30 days) MO
mirtazapine odt $0(Tier 1) QL (30 per 30 days) MO
nefazodone hcl $0(Tier 1) QL (60 per 30 days) MO
trazodone hcl tabs $0(Tier 1) MO
TRINTELLIX $0(Tier 2) QL (30 per 30 days) ST
Monoamine Oxidase Inhibitors
EMSAM $0(Tier 2) MO
MARPLAN $0(Tier 2)
14 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
phenelzine sulfate $0(Tier 1) MO
tranylcypromine sulfate $0(Tier 1) MO
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide soln $0(Tier 1) QL (600 per 30 days) MO
citalopram hydrobromide tabs 40mg $0(Tier 1) QL (30 per 30 days) MO
citalopram hydrobromide tabs 10mg, 20mg $0(Tier 1) QL (60 per 30 days) MO
duloxetine hcl cpep 20mg, 60mg $0(Tier 1) QL (60 per 30 days) MO
duloxetine hcl cpep 30mg $0(Tier 1) QL (90 per 30 days) MO
escitalopram oxalate $0(Tier 1) MO
FETZIMA $0(Tier 2) QL (30 per 30 days) ST
MO
FETZIMA TITRATION PACK $0(Tier 2) QL (28 per 28 days) ST
MO
fluoxetine $0(Tier 1)
fluoxetine dr $0(Tier 1) MO
fluoxetine hcl caps, soln $0(Tier 1) MO
fluoxetine hcl tabs 10mg, 20mg $0(Tier 1)
fluvoxamine maleate $0(Tier 1) MO
fluvoxamine maleate er cp24 150mg $0(Tier 1) QL (60 per 30 days)
fluvoxamine maleate er cp24 100mg $0(Tier 1) QL (90 per 30 days)
olanzapine/fluoxetine $0(Tier 1) QL (30 per 30 days) MO
paroxetine hcl er tb24 12.5mg $0(Tier 1) QL (30 per 30 days) MO
paroxetine hcl er tb24 37.5mg $0(Tier 1) QL (60 per 30 days) MO
paroxetine hcl er tb24 25mg $0(Tier 1) QL (90 per 30 days) MO
paroxetine hcl tabs 10mg $0(Tier 1) QL (30 per 30 days) MO
paroxetine hcl tabs 20mg, 30mg, 40mg $0(Tier 1) QL (60 per 30 days) MO
PAXIL SUSP $0(Tier 2) QL (900 per 30 days) ST
PRISTIQ TB24 25MG $0(Tier 2) QL (30 per 30 days)
PRISTIQ TB24 100MG, 50MG $0(Tier 2) QL (30 per 30 days) MO
sertraline hcl conc $0(Tier 1) QL (300 per 30 days) MO
sertraline hcl tabs 25mg $0(Tier 1) QL (30 per 30 days) MO
sertraline hcl tabs 100mg $0(Tier 1) QL (60 per 30 days) MO
sertraline hcl tabs 50mg $0(Tier 1) QL (90 per 30 days) MO
venlafaxine hcl $0(Tier 1) MO
venlafaxine hcl er cp24 $0(Tier 1) MO
venlafaxine hcl er tb24 150mg, 37.5mg, 75mg $0(Tier 1) MO
VIIBRYD $0(Tier 2) QL (30 per 30 days) ST
MO
VIIBRYD STARTER PACK $0(Tier 2) QL (30 per 30 days) ST
Tricyclics
amitriptyline hcl tabs $0(Tier 1) PA MO
15 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
amoxapine $0(Tier 1) MO
clomipramine hcl caps $0(Tier 1) PA MO
desipramine hcl tabs $0(Tier 1) MO
doxepin hcl caps, conc $0(Tier 1) PA MO
imipramine hcl tabs $0(Tier 1) PA MO
imipramine pamoate $0(Tier 1) PA MO
nortriptyline hcl soln $0(Tier 1)
nortriptyline hcl caps $0(Tier 1) MO
perphenazine/amitriptyline $0(Tier 1) PA MO
protriptyline hcl $0(Tier 1) MO
SURMONTIL $0(Tier 2) PA MO
trimipramine maleate caps $0(Tier 1) PA
Antiemetics (Drugs that Prevent or Treat Nausea and Vomiting)
Antiemetics, Other
dimenhydrinate tabs $0(Tier 1) MC
formula em $0(Tier 1) MC
meclizine hcl tabs 12.5mg, 25mg $0(Tier 1)
meclizine hcl tabs 12.5mg $0(Tier 1) MC
promethazine hcl plain $0(Tier 1) PA
promethazine hcl syrp, tabs $0(Tier 1) PA
TRANSDERM-SCOP $0(Tier 2) QL (12 per 36 days)
travel sickness $0(Tier 1) MC
Antiemetics
granisetron hcl inj 1mg/ml $0(Tier 1) B/D
Emetogenic Therapy Adjuncts
ALOXI $0(Tier 2) B/D
dronabinol $0(Tier 1) QL (90 per 30 days) PA
EMEND SUSR $0(Tier 2) QL (6 per 28 days) B/D
EMEND CAPS 0 $0(Tier 2) QL (12 per 30 days) B/D
EMEND CAPS 40MG $0(Tier 2) QL (2 per 30 days) B/D
EMEND CAPS 125MG $0(Tier 2) QL (4 per 30 days) B/D
EMEND CAPS 80MG $0(Tier 2) QL (8 per 30 days) B/D
granisetron hcl inj 0.1mg/ml, 1mg/ml $0(Tier 1) B/D
granisetron hcl tabs 1mg $0(Tier 1) QL (60 per 30 days) B/D
ondansetron hcl oral soln $0(Tier 1) B/D
ondansetron hcl inj 40mg/20ml, 4mg/2ml $0(Tier 1)
ondansetron hcl tabs 24mg $0(Tier 1) B/D
ondansetron hcl tabs 4mg, 8mg $0(Tier 1) QL (90 per 30 days) B/D
ondansetron odt $0(Tier 1) QL (90 per 30 days) B/D
Antifungals (Drugs that treat Infections with Fungus)
Antifungals
ABELCET $0(Tier 2) PA
16 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
AMBISOME $0(Tier 2) PA
amphotericin b $0(Tier 1) PA
anti-fungal powder $0(Tier 1) MC
antifungal $0(Tier 1) MC
CANCIDAS $0(Tier 2) PA
ciclodan $0(Tier 1)
ciclopirox nail lacquer $0(Tier 1)
ciclopirox olamine crea $0(Tier 1)
ciclopirox sham, susp $0(Tier 1)
clotrimazole anti-fungal $0(Tier 1) MC
clotrimazole/betamethasone dipropionate $0(Tier 1)
clotrimazole external crea 1% $0(Tier 1)
clotrimazole external crea 1% $0(Tier 1) MC
clotrimazole vaginal crea 1% $0(Tier 1) MC
clotrimazole troc $0(Tier 1)
clotrimazole soln 1% $0(Tier 1)
clotrimazole soln 1% $0(Tier 1) MC
econazole nitrate crea $0(Tier 1)
fluconazole in dextrose $0(Tier 1)
fluconazole in nacl $0(Tier 1)
fluconazole susr $0(Tier 1)
fluconazole tabs 100mg, 200mg, 50mg $0(Tier 1)
fluconazole tabs 150mg $0(Tier 1) QL (8 per 30 days)
flucytosine $0(Tier 1)
FUNGOID TINCTURE SOLN $0(Tier 1) MC
griseofulvin microsize $0(Tier 1)
griseofulvin ultramicrosize $0(Tier 1)
itraconazole caps $0(Tier 1) QL (120 per 30 days) PA
ketoconazole crea, sham, tabs $0(Tier 1)
miconazole 7 supp $0(Tier 1) MC
miconazole nitrate external crea, vaginal crea, supp $0(Tier 1) MC
miconazole crea $0(Tier 1) MC
naftifine hcl $0(Tier 1)
naftifine hydrochloride $0(Tier 1)
NAFTIN GEL $0(Tier 2)
NAFTIN CREA 2% $0(Tier 2)
NATACYN $0(Tier 2)
NOXAFIL SUSP $0(Tier 2) QL (600 per 30 days) PA
NOXAFIL TBEC $0(Tier 2) QL (93 per 30 days) PA
nyamyc $0(Tier 1)
nystatin/triamcinolone $0(Tier 1)
nystatin crea, oint, powd, susp, tabs $0(Tier 1)
17 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
nystop $0(Tier 1)
qc tolnaftate $0(Tier 1) MC
sm miconazole 7 crea $0(Tier 1) MC
SPORANOX SOLN $0(Tier 2) PA
terbinafine hcl crea $0(Tier 1) MC
terbinafine hcl tabs $0(Tier 1) QL (180 per 365 days)
terconazole $0(Tier 1)
tioconazole-1 $0(Tier 1) MC
tolnaftate crea, powd $0(Tier 1) MC
voriconazole inj, susr, tabs $0(Tier 1) PA
ZEASORB-AF POWD $0(Tier 1) MC
Antigout Agents (Drugs that Treat or Prevent Gout)
Antigout Agents
allopurinol tabs $0(Tier 1) MO
ALOPRIM $0(Tier 2)
colchicine caps, tabs $0(Tier 1)
COLCRYS $0(Tier 2) MO
probenecid/colchicine $0(Tier 1) MO
probenecid tabs $0(Tier 1) MO
ULORIC $0(Tier 2) ST
Antimigraine Agents (Drugs that Treat Migraine Headaches)
Ergot Alkaloids
CAFERGOT $0(Tier 2)
dihydroergotamine mesylate inj $0(Tier 1)
MIGERGOT $0(Tier 2)
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan hcl $0(Tier 1) QL (9 per 30 days)
rizatriptan benzoate $0(Tier 1) QL (12 per 30 days)
rizatriptan benzoate odt $0(Tier 1) QL (12 per 30 days)
sumatriptan succinate refill $0(Tier 1) QL (8 per 30 days)
sumatriptan succinate inj $0(Tier 1) QL (8 per 30 days)
sumatriptan succinate tabs $0(Tier 1) QL (9 per 30 days)
sumatriptan soln $0(Tier 1) QL (12 per 30 days)
Antimyasthenic Agents (Drugs used for Problems with Muscle Weakness and Fatigue)
Parasympathomimetics
GUANIDINE HCL $0(Tier 2)
MESTINON TIMESPAN $0(Tier 2)
pyridostigmine bromide er $0(Tier 1)
pyridostigmine bromide tabs $0(Tier 1)
REGONOL $0(Tier 2)
Antimycobacterials (Drugs that Treat Infection with Fungus and Bacteria)
Antimycobacterials, Other
18 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
dapsone tabs $0(Tier 1) MO
rifabutin $0(Tier 1)
Antituberculars
CAPASTAT SULFATE $0(Tier 2)
cycloserine $0(Tier 1)
ethambutol hcl $0(Tier 1)
isoniazid inj, syrp, tabs $0(Tier 1)
PASER $0(Tier 2)
pyrazinamide tabs $0(Tier 1)
rifampin caps, inj $0(Tier 1)
RIFATER $0(Tier 2)
SIRTURO $0(Tier 2) PA
TRECATOR $0(Tier 2)
Antineoplastics (Drugs that Treat Cancer)
Alkylating Agents
BENDEKA $0(Tier 2) B/D
BICNU $0(Tier 2) B/D
BUSULFEX $0(Tier 2) B/D
cyclophosphamide caps, inj, tabs $0(Tier 1) B/D
dacarbazine $0(Tier 1) B/D
EVOMELA $0(Tier 2) PA
GLEOSTINE $0(Tier 2)
HEXALEN $0(Tier 2)
ifosfamide $0(Tier 1) B/D
LEUKERAN $0(Tier 2)
LOMUSTINE $0(Tier 2)
MATULANE $0(Tier 2)
melphalan hydrochloride $0(Tier 1) B/D
MUSTARGEN $0(Tier 2) B/D
thiotepa $0(Tier 1) PA
TREANDA $0(Tier 2) B/D
VALCHLOR $0(Tier 2) PA
YONDELIS $0(Tier 2) PA
ZANOSAR $0(Tier 2) B/D
Antiandrogens
bicalutamide $0(Tier 1)
flutamide $0(Tier 1)
NILANDRON $0(Tier 2)
nilutamide $0(Tier 1)
XTANDI $0(Tier 2) QL (120 per 30 days) PA
ZYTIGA $0(Tier 2) QL (120 per 30 days) PA
Antiangiogenic Agents
19 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
POMALYST $0(Tier 2) QL (21 per 28 days) PA
REVLIMID $0(Tier 2) QL (28 per 28 days) PA
THALOMID CAPS 150MG, 200MG, 50MG $0(Tier 2) QL (60 per 30 days) PA
THALOMID CAPS 100MG $0(Tier 2) QL (90 per 30 days) PA
Antiestrogens/Modifiers
EMCYT $0(Tier 2)
FARESTON $0(Tier 2) MO
FASLODEX $0(Tier 2) B/D
SOLTAMOX $0(Tier 2)
tamoxifen citrate tabs $0(Tier 1) MO
Antimetabolites
adrucil $0(Tier 1) B/D
ALIMTA INJ 500MG $0(Tier 2) B/D
ARRANON $0(Tier 2)
cladribine $0(Tier 1) B/D
CLOLAR $0(Tier 2) B/D
cytarabine $0(Tier 1) B/D
cytarabine aqueous $0(Tier 1) B/D
DROXIA $0(Tier 2) MO
ELITEK $0(Tier 2) B/D
fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml,
5gm/100ml
$0(Tier 1) B/D
FOLOTYN $0(Tier 2) B/D
gemcitabine $0(Tier 1) B/D
gemcitabine hcl $0(Tier 1) B/D
hydroxyurea caps $0(Tier 1)
LONSURF TABS 6.14MG; 15MG $0(Tier 2) QL (100 per 28 days) PA
LONSURF TABS 8.19MG; 20MG $0(Tier 2) QL (80 per 28 days) PA
mercaptopurine tabs $0(Tier 1)
NIPENT $0(Tier 2) B/D
PURIXAN $0(Tier 2) PA
TABLOID $0(Tier 2)
Antineoplastics, Other
ABRAXANE $0(Tier 2) B/D
amifostine $0(Tier 1) B/D
azacitidine $0(Tier 1) B/D
BELEODAQ $0(Tier 2) PA
bleomycin sulfate $0(Tier 1) B/D
carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml $0(Tier 1) B/D
carboplatin inj 600mg/60ml $0(Tier 1) B/D MO
cisplatin $0(Tier 1) B/D
COSMEGEN $0(Tier 2) B/D
20 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
daunorubicin hcl $0(Tier 1) B/D
DECITABINE $0(Tier 2)
dexrazoxane $0(Tier 1) B/D
DOCEFREZ INJ 20MG $0(Tier 2) B/D
docetaxel $0(Tier 1) B/D
doxorubicin hcl $0(Tier 1) B/D
doxorubicin hcl liposome $0(Tier 1) B/D
epirubicin hcl inj 200mg/100ml, 50mg/25ml $0(Tier 1) B/D
ERWINAZE $0(Tier 2) B/D
fludarabine phosphate $0(Tier 1) B/D
FUSILEV $0(Tier 2)
HALAVEN $0(Tier 2) PA
idarubicin hcl inj 10mg/10ml $0(Tier 1) B/D
irinotecan $0(Tier 1) B/D
ISTODAX $0(Tier 2) PA MO
IXEMPRA KIT $0(Tier 2) B/D
JEVTANA $0(Tier 2) B/D
leucovorin calcium tabs $0(Tier 1)
leucovorin calcium inj 100mg, 350mg, 500mg, 50mg $0(Tier 1)
levoleucovorin calcium $0(Tier 1)
levoleucovorin inj 250mg/25ml, 50mg $0(Tier 1)
mesna $0(Tier 1) B/D
MESNEX TABS $0(Tier 2)
mitomycin $0(Tier 1) B/D
mitoxantrone hcl $0(Tier 1) B/D
NINLARO $0(Tier 2) QL (3 per 28 days) PA
ODOMZO $0(Tier 2) QL (30 per 30 days) PA
ONCASPAR $0(Tier 2) B/D
oxaliplatin $0(Tier 1) B/D
paclitaxel $0(Tier 1) B/D
PORTRAZZA $0(Tier 2) QL (100 per 21 days) PA
PROLEUKIN $0(Tier 2) B/D
SYLATRON $0(Tier 2) PA
SYNRIBO $0(Tier 2) PA
TRISENOX $0(Tier 2) B/D
VELCADE $0(Tier 2) B/D
VENCLEXTA STARTING PACK $0(Tier 2) QL (84 per 365 days) PA
VENCLEXTA TABS 100MG $0(Tier 2) QL (120 per 30 days) PA
VENCLEXTA TABS 50MG $0(Tier 2) QL (30 per 30 days) PA
VENCLEXTA TABS 10MG $0(Tier 2) QL (60 per 30 days) PA
vinblastine sulfate $0(Tier 1) B/D
vincasar pfs $0(Tier 1) B/D
21 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
vincristine sulfate $0(Tier 1) B/D
vinorelbine tartrate $0(Tier 1) B/D
ZOLINZA $0(Tier 2) QL (120 per 30 days)
Aromatase Inhibitors, 3rd Generation
anastrozole tabs $0(Tier 1) QL (30 per 30 days) MO
exemestane $0(Tier 1)
letrozole $0(Tier 1) QL (30 per 30 days)
Enzyme Inhibitors
ETOPOPHOS $0(Tier 2) B/D
etoposide inj $0(Tier 1) B/D
toposar $0(Tier 1) B/D
topotecan hcl inj 4mg $0(Tier 1)
ZYDELIG $0(Tier 2) QL (60 per 30 days) PA
Molecular Target Inhibitors
AFINITOR DISPERZ TBSO 5MG $0(Tier 2) QL (120 per 30 days) PA
MO
AFINITOR DISPERZ TBSO 2MG, 3MG $0(Tier 2) QL (60 per 30 days) PA
MO
AFINITOR TABS 2.5MG, 5MG, 7.5MG $0(Tier 2) QL (30 per 30 days) PA
AFINITOR TABS 10MG $0(Tier 2) QL (60 per 30 days) PA
ALECENSA $0(Tier 2) QL (240 per 30 days) PA
BOSULIF $0(Tier 2) PA
CABOMETYX TABS 20MG, 60MG $0(Tier 2) QL (30 per 30 days) PA
CABOMETYX TABS 40MG $0(Tier 2) QL (60 per 30 days) PA
CAPRELSA $0(Tier 2) PA
COMETRIQ $0(Tier 2) PA
COTELLIC $0(Tier 2) QL (63 per 28 days) PA
ERIVEDGE $0(Tier 2) QL (30 per 30 days) PA
FARYDAK $0(Tier 2) QL (9 per 28 days) PA
GILOTRIF $0(Tier 2) QL (30 per 30 days) PA
GLEEVEC $0(Tier 2) QL (60 per 30 days) PA
IBRANCE $0(Tier 2) QL (21 per 28 days) PA
ICLUSIG $0(Tier 2) PA
imatinib mesylate $0(Tier 1) QL (60 per 30 days) PA
IMBRUVICA $0(Tier 2) QL (120 per 30 days) PA
INLYTA TABS 5MG $0(Tier 2) QL (120 per 30 days) PA
INLYTA TABS 1MG $0(Tier 2) QL (240 per 30 days) PA
IRESSA $0(Tier 2) QL (30 per 30 days) PA
JAKAFI $0(Tier 2) QL (60 per 30 days) PA
LENVIMA 10 MG DAILY DOSE $0(Tier 2) PA
LENVIMA 14 MG DAILY DOSE $0(Tier 2) PA
LENVIMA 18 MG DAILY DOSE $0(Tier 2) QL (90 per 30 days) PA
22 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
LENVIMA 20 MG DAILY DOSE $0(Tier 2) PA
LENVIMA 24 MG DAILY DOSE $0(Tier 2) PA
LENVIMA 8 MG DAILY DOSE $0(Tier 2) QL (60 per 30 days) PA
LYNPARZA $0(Tier 2) QL (480 per 30 days) PA
MEKINIST $0(Tier 2) PA
NEXAVAR $0(Tier 2) PA
SPRYCEL $0(Tier 2) PA
STIVARGA $0(Tier 2) QL (84 per 21 days) PA
SUTENT $0(Tier 2) PA
TAFINLAR $0(Tier 2) PA
TAGRISSO $0(Tier 2) QL (30 per 30 days) PA
TARCEVA $0(Tier 2) PA
TASIGNA $0(Tier 2) PA
TYKERB $0(Tier 2) PA
VOTRIENT $0(Tier 2) QL (120 per 30 days) PA
XALKORI $0(Tier 2) QL (60 per 30 days) PA
ZELBORAF $0(Tier 2) QL (240 per 30 days) PA
ZYKADIA $0(Tier 2) PA
Monoclonal Antibodies
ARZERRA $0(Tier 2) B/D MO
AVASTIN $0(Tier 2) B/D
CYRAMZA $0(Tier 2) PA
DARZALEX $0(Tier 2) PA
EMPLICITI $0(Tier 2) PA
ERBITUX $0(Tier 2) B/D
GAZYVA $0(Tier 2) PA
HERCEPTIN $0(Tier 2) B/D
KADCYLA $0(Tier 2) PA
KEYTRUDA $0(Tier 2) PA
OPDIVO $0(Tier 2) PA
PERJETA $0(Tier 2) PA
RITUXAN INJ 500MG/50ML $0(Tier 2) PA
TECENTRIQ $0(Tier 2) QL (20 per 21 days) PA
UNITUXIN $0(Tier 2) PA
VECTIBIX INJ 100MG/5ML $0(Tier 2) B/D
YERVOY $0(Tier 2) B/D
ZALTRAP $0(Tier 2) PA
Retinoids
bexarotene $0(Tier 1)
PANRETIN $0(Tier 2)
TARGRETIN $0(Tier 2)
tretinoin caps 10mg $0(Tier 1) MO
23 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
Antiparasitics (Drugs that Treat Infections with Parasites)
Anthelmintics
ALBENZA $0(Tier 2)
ivermectin tabs $0(Tier 1)
Antiprotozoals
ALINIA $0(Tier 2)
atovaquone $0(Tier 1)
atovaquone/proguanil hcl $0(Tier 1)
chloroquine phosphate tabs $0(Tier 1) MO
COARTEM $0(Tier 2)
DARAPRIM $0(Tier 2)
hydroxychloroquine sulfate tabs $0(Tier 1) MO
mefloquine hcl $0(Tier 1) MO
NEBUPENT $0(Tier 2) B/D
PENTAM 300 $0(Tier 2)
PRIMAQUINE PHOSPHATE TABS $0(Tier 2)
quinine sulfate $0(Tier 1)
Pediculicides/Scabicides
lindane lotn, sham $0(Tier 1)
malathion $0(Tier 1)
permethrin crea $0(Tier 1)
permethrin lotn $0(Tier 1) MC
Antiparkinson Agents (Drugs used for Parkinson’s Disease)
Anticholinergics
benztropine mesylate inj $0(Tier 1) MO
benztropine mesylate tabs $0(Tier 1) PA MO
trihexyphenidyl hcl $0(Tier 1) PA MO
Antiparkinson Agents, Other
entacapone $0(Tier 1) MO
tolcapone $0(Tier 1) MO
Dopamine Agonists
APOKYN $0(Tier 2) QL (60 per 30 days) PA
MO
bromocriptine mesylate caps, tabs $0(Tier 1) MO
NEUPRO $0(Tier 2) QL (30 per 30 days)
pramipexole dihydrochloride $0(Tier 1) QL (90 per 30 days) MO
pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 4.5mg $0(Tier 1) QL (30 per 30 days)
pramipexole dihydrochloride er tb24 3mg $0(Tier 1) QL (30 per 30 days) MO
pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg $0(Tier 1) QL (90 per 30 days) MO
ropinirole hcl $0(Tier 1) MO
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa $0(Tier 1) MO
24 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
carbidopa/levodopa er $0(Tier 1) MO
carbidopa/levodopa odt $0(Tier 1) MO
carbidopa/levodopa/entacapone $0(Tier 1) MO
carbidopa tabs $0(Tier 1) MO
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT $0(Tier 2)
selegiline hcl caps, tabs $0(Tier 1) MO
Antipsychotics (Drugs that Control or Prevent Psychotic Behavior)
1st Generation/Typical
chlorpromazine hcl tabs $0(Tier 1) MO
chlorpromazine hcl inj 50mg/2ml $0(Tier 1)
compro $0(Tier 1)
fluphenazine decanoate inj $0(Tier 1)
fluphenazine hcl inj $0(Tier 1)
fluphenazine hcl conc, elix, tabs $0(Tier 1) MO
haloperidol decanoate $0(Tier 1)
haloperidol lactate $0(Tier 1)
haloperidol conc, tabs $0(Tier 1) MO
loxapine $0(Tier 1) MO
loxapine succinate $0(Tier 1) MO
ORAP $0(Tier 2) MO
perphenazine tabs $0(Tier 1) MO
pimozide $0(Tier 1)
prochlorperazine $0(Tier 1)
prochlorperazine edisylate inj $0(Tier 1)
prochlorperazine maleate tabs $0(Tier 1)
thioridazine hcl tabs $0(Tier 1) PA MO
thiothixene $0(Tier 1) MO
trifluoperazine hcl tabs $0(Tier 1) MO
2nd Generation/Atypical
ABILIFY DISCMELT $0(Tier 2) QL (60 per 30 days) ST
MO
ABILIFY MAINTENA INJ 300MG $0(Tier 2) QL (1.5 per 30 days) MO
ABILIFY MAINTENA INJ 400MG $0(Tier 2) QL (2 per 30 days) MO
aripiprazole odt $0(Tier 1) QL (60 per 30 days) ST
aripiprazole tabs $0(Tier 1) QL (30 per 30 days) ST
MO
aripiprazole soln $0(Tier 1) QL (900 per 30 days) ST
ARISTADA INJ 441MG/1.6ML $0(Tier 2) QL (1.6 per 30 days)
ARISTADA INJ 662MG/2.4ML $0(Tier 2) QL (2.4 per 30 days)
ARISTADA INJ 882MG/3.2ML $0(Tier 2) QL (3.2 per 30 days)
25 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
FANAPT $0(Tier 2) QL (60 per 30 days) ST
MO
FANAPT TITRATION PACK $0(Tier 2) QL (16 per 30 days) ST
MO
GEODON INJ $0(Tier 2) QL (60 per 30 days)
INVEGA SUSTENNA INJ 39MG/0.25ML $0(Tier 2) QL (0.25 per 28 days) MO
INVEGA SUSTENNA INJ 78MG/0.5ML $0(Tier 2) QL (0.5 per 28 days) MO
INVEGA SUSTENNA INJ 117MG/0.75ML $0(Tier 2) QL (0.75 per 28 days) MO
INVEGA SUSTENNA INJ 156MG/ML $0(Tier 2) QL (1 per 28 days) MO
INVEGA SUSTENNA INJ 234MG/1.5ML $0(Tier 2) QL (1.5 per 28 days) MO
INVEGA TRINZA INJ 273MG/0.875ML $0(Tier 2) QL (0.88 per 90 days)
INVEGA TRINZA INJ 410MG/1.315ML $0(Tier 2) QL (1.32 per 90 days)
INVEGA TRINZA INJ 546MG/1.75ML $0(Tier 2) QL (1.75 per 90 days)
INVEGA TRINZA INJ 819MG/2.625ML $0(Tier 2) QL (2.63 per 90 days)
INVEGA TB24 1.5MG, 3MG, 9MG $0(Tier 2) QL (30 per 30 days) ST
INVEGA TB24 6MG $0(Tier 2) QL (60 per 30 days) ST
LATUDA TABS 120MG, 20MG, 40MG, 60MG $0(Tier 2) QL (30 per 30 days) ST
MO
LATUDA TABS 80MG $0(Tier 2) QL (60 per 30 days) ST
MO
NUPLAZID $0(Tier 2) QL (60 per 30 days) PA
olanzapine odt $0(Tier 1) QL (30 per 30 days) MO
olanzapine inj $0(Tier 1)
olanzapine tabs $0(Tier 1) QL (30 per 30 days) MO
paliperidone er tb24 1.5mg, 3mg, 9mg $0(Tier 1) QL (30 per 30 days) ST
paliperidone er tb24 6mg $0(Tier 1) QL (60 per 30 days) ST
quetiapine fumarate $0(Tier 1) QL (90 per 30 days) MO
REXULTI $0(Tier 2) QL (30 per 30 days) ST
RISPERDAL CONSTA $0(Tier 2)
risperidone m-tab tbdp 4mg $0(Tier 1) QL (120 per 30 days) MO
risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (90 per 30 days) MO
risperidone odt tbdp 4mg $0(Tier 1) QL (120 per 30 days) MO
risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (90 per 30 days) MO
risperidone soln $0(Tier 1) QL (360 per 30 days) MO
risperidone tabs 4mg $0(Tier 1) QL (120 per 30 days) MO
risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (90 per 30 days) MO
SAPHRIS $0(Tier 2) QL (60 per 30 days) ST
SEROQUEL XR TB24 150MG, 200MG $0(Tier 2) QL (30 per 30 days) MO
SEROQUEL XR TB24 300MG, 400MG, 50MG $0(Tier 2) QL (60 per 30 days) MO
VRAYLAR CPPK $0(Tier 2) QL (14 per 365 days) ST
VRAYLAR CAPS $0(Tier 2) QL (30 per 30 days) ST
ziprasidone hcl $0(Tier 1) QL (60 per 30 days) MO
26 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
ZYPREXA RELPREVV $0(Tier 2)
Antipsychotics
molindone hydrochloride $0(Tier 1)
Treatment-Resistant
clozapine $0(Tier 1)
clozapine odt tbdp 100mg, 150mg, 200mg, 25mg $0(Tier 1)
clozapine odt tbdp 12.5mg $0(Tier 1) MO
FAZACLO TBDP 100MG $0(Tier 2) ST
FAZACLO TBDP 12.5MG, 25MG $0(Tier 2) ST MO
VERSACLOZ $0(Tier 2)
Antispasticity Agents (Drugs used for Muscle Jerks or Twitches)
Antispasticity Agents
baclofen tabs $0(Tier 1) MO
dantrolene sodium caps $0(Tier 1)
tizanidine hcl tabs $0(Tier 1) MO
Antivirals (Drugs that Treat Infection with Viruses)
Anti-cytomegalovirus (CMV) Agents
cidofovir $0(Tier 1)
ganciclovir inj $0(Tier 1) B/D
VALCYTE SOLR $0(Tier 2) MO
valganciclovir $0(Tier 1)
valganciclovir hydrochlorde $0(Tier 1)
ZIRGAN $0(Tier 2) ST
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil $0(Tier 1) QL (30 per 30 days) MO
BARACLUDE SOLN $0(Tier 2) MO
entecavir $0(Tier 1)
EPIVIR HBV SOLN $0(Tier 2) MO
INTRON A $0(Tier 2)
INTRON A W/DILUENT $0(Tier 2)
lamivudine tabs 100mg $0(Tier 1) MO
TYZEKA $0(Tier 2) PA MO
Anti-hepatitis C (HCV) Agents
HARVONI $0(Tier 2) QL (28 per 28 days) PA
MO
moderiba $0(Tier 1) PA
moderiba 1200 dose pack $0(Tier 1) PA
moderiba 800 dose pack $0(Tier 1) PA
OLYSIO $0(Tier 2) QL (28 per 28 days) PA
MO
PEG-INTRON REDIPEN $0(Tier 2) PA
PEG-INTRON REDIPEN PAK 4 $0(Tier 2) PA
27 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
PEGINTRON $0(Tier 2) PA
REBETOL SOLN $0(Tier 2) PA
RIBASPHERE RIBAPAK TABS 0 $0(Tier 2) PA
ribasphere ribapak tabs 400mg, 600mg $0(Tier 1) PA
ribasphere caps $0(Tier 1) PA
RIBASPHERE TABS 400MG, 600MG $0(Tier 2) PA
ribasphere tabs 200mg $0(Tier 1) PA
RIBATAB $0(Tier 2) PA
ribavirin $0(Tier 1) PA
SOVALDI $0(Tier 2) QL (28 per 28 days) PA
MO
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA $0(Tier 2)
ISENTRESS PACK $0(Tier 2)
ISENTRESS TABS $0(Tier 2) QL (60 per 30 days) MO
ISENTRESS CHEW 100MG $0(Tier 2) QL (180 per 30 days)
ISENTRESS CHEW 25MG $0(Tier 2) QL (360 per 30 days)
TIVICAY $0(Tier 2) QL (60 per 30 days)
VITEKTA $0(Tier 2) MO
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA $0(Tier 2) MO
EDURANT $0(Tier 2)
INTELENCE TABS 100MG $0(Tier 2) QL (120 per 30 days) MO
INTELENCE TABS 25MG $0(Tier 2) QL (180 per 30 days) MO
INTELENCE TABS 200MG $0(Tier 2) QL (60 per 30 days)
nevirapine $0(Tier 1) MO
nevirapine er tb24 100mg $0(Tier 1)
nevirapine er tb24 400mg $0(Tier 1) MO
ODEFSEY $0(Tier 2) QL (30 per 30 days)
RESCRIPTOR $0(Tier 2) MO
STRIBILD $0(Tier 2) MO
SUSTIVA $0(Tier 2) MO
VIRAMUNE XR TB24 100MG $0(Tier 2)
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir $0(Tier 1) MO
abacavir sulfate/lamivudine/zidovudine $0(Tier 1) MO
abacavir/lamivudine $0(Tier 1)
DESCOVY $0(Tier 2) QL (30 per 30 days)
didanosine $0(Tier 1) MO
EMTRIVA $0(Tier 2) MO
28 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
EPZICOM $0(Tier 2) MO
lamivudine/zidovudine $0(Tier 1) MO
lamivudine soln 10mg/ml $0(Tier 1)
lamivudine tabs 150mg, 300mg $0(Tier 1) MO
RETROVIR IV INFUSION $0(Tier 2)
stavudine solr $0(Tier 1)
stavudine caps $0(Tier 1) MO
TRIUMEQ $0(Tier 2) QL (30 per 30 days)
TRUVADA TABS 100MG; 150MG, 133MG; 200MG,
167MG; 250MG
$0(Tier 2)
TRUVADA TABS 200MG; 300MG $0(Tier 2) MO
VIDEX PEDIATRIC $0(Tier 2) MO
VIREAD $0(Tier 2) MO
ZIAGEN SOLN $0(Tier 2) MO
zidovudine $0(Tier 1) MO
Anti-HIV Agents, Other
ATRIPLA $0(Tier 2) MO
FUZEON $0(Tier 2) QL (60 per 30 days) MO
SELZENTRY TABS 300MG $0(Tier 2) QL (120 per 30 days) MO
SELZENTRY TABS 150MG $0(Tier 2) QL (60 per 30 days) MO
TYBOST $0(Tier 2)
Anti-HIV Agents, Protease Inhibitors
APTIVUS $0(Tier 2) MO
CRIXIVAN $0(Tier 2) MO
EVOTAZ $0(Tier 2)
INVIRASE $0(Tier 2) MO
KALETRA $0(Tier 2) MO
LEXIVA $0(Tier 2) MO
NORVIR $0(Tier 2) MO
PREZCOBIX $0(Tier 2)
PREZISTA SUSP $0(Tier 2) QL (400 per 30 days)
PREZISTA TABS 150MG $0(Tier 2) QL (180 per 30 days) MO
PREZISTA TABS 800MG $0(Tier 2) QL (30 per 30 days) MO
PREZISTA TABS 75MG $0(Tier 2) QL (360 per 30 days) MO
PREZISTA TABS 600MG $0(Tier 2) QL (60 per 30 days) MO
REYATAZ PACK $0(Tier 2)
REYATAZ CAPS $0(Tier 2) MO
VIRACEPT $0(Tier 2) MO
Anti-influenza Agents
amantadine hcl syrp $0(Tier 1)
amantadine hcl caps, tabs $0(Tier 1) MO
rimantadine hcl $0(Tier 1)
29 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
TAMIFLU SUSR $0(Tier 2) QL (700 per 365 days)
TAMIFLU CAPS 30MG $0(Tier 2) QL (120 per 365 days)
TAMIFLU CAPS 75MG $0(Tier 2) QL (56 per 365 days)
TAMIFLU CAPS 45MG $0(Tier 2) QL (60 per 365 days)
Antiherpetic Agents
acyclovir sodium inj 50mg/ml $0(Tier 1)
acyclovir caps, oint, susp, tabs $0(Tier 1)
DENAVIR $0(Tier 2)
famciclovir tabs $0(Tier 1) QL (21 per 7 days)
trifluridine soln $0(Tier 1)
valacyclovir hcl tabs 1000mg $0(Tier 1) QL (30 per 30 days)
valacyclovir hcl tabs 500mg $0(Tier 1) QL (60 per 30 days)
ZOVIRAX CREA $0(Tier 2)
Anxiolytics (Drugs used to Relieve Stress or Anxiety)
Anxiolytics, Other
buspirone hcl tabs $0(Tier 1)
Benzodiazepines
alprazolam odt tbdp 1mg $0(Tier 1) QL (120 per 30 days)
alprazolam odt tbdp 2mg $0(Tier 1) QL (150 per 30 days)
alprazolam odt tbdp 0.25mg, 0.5mg $0(Tier 1) QL (90 per 30 days)
alprazolam tabs 1mg $0(Tier 1) QL (120 per 30 days)
alprazolam tabs 2mg $0(Tier 1) QL (150 per 30 days)
alprazolam tabs 0.25mg, 0.5mg $0(Tier 1) QL (90 per 30 days)
clorazepate dipotassium tabs 15mg $0(Tier 1) QL (120 per 30 days)
clorazepate dipotassium tabs 3.75mg, 7.5mg $0(Tier 1) QL (90 per 30 days)
diazepam inj 5mg/ml $0(Tier 1)
diazepam oral soln 1mg/ml $0(Tier 1) QL (1200 per 30 days)
diazepam tabs 10mg, 2mg, 5mg $0(Tier 1) QL (120 per 30 days)
lorazepam intensol $0(Tier 1) QL (150 per 30 days)
lorazepam tabs $0(Tier 1) QL (120 per 30 days) MO
lorazepam conc $0(Tier 1) QL (150 per 30 days) MO
lorazepam inj 2mg/ml, 4mg/ml $0(Tier 1)
oxazepam $0(Tier 1) QL (120 per 30 days) MO
Bipolar Agents (Drugs that Regulate Severe Mood Changes due to Bipolar Disorder)
Mood Stabilizers
lithium carbonate er $0(Tier 1) MO
lithium carbonate caps, tabs $0(Tier 1) MO
Blood Glucose Regulators (Drugs used to Control Blood Sugar Levels)
Antidiabetic Agents
acarbose $0(Tier 1) QL (90 per 30 days) MO
BYDUREON $0(Tier 2) QL (4 per 28 days) MO
BYDUREON PEN $0(Tier 2) QL (4 per 28 days) MO
30 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
BYETTA $0(Tier 2) QL (2.4 per 30 days) MO
CYCLOSET $0(Tier 2)
glimepiride tabs 1mg, 2mg $0(Tier 1) QL (30 per 30 days) MO
glimepiride tabs 4mg $0(Tier 1) QL (60 per 30 days) MO
glipizide er $0(Tier 1) MO
glipizide xl $0(Tier 1)
glipizide/metformin hcl $0(Tier 1) MO
glipizide tabs $0(Tier 1) MO
GLYSET $0(Tier 2) MO
INVOKAMET $0(Tier 2) QL (60 per 30 days) MO
INVOKAMET XR $0(Tier 2) QL (60 per 30 days)
INVOKANA $0(Tier 2) QL (30 per 30 days) MO
JANUMET $0(Tier 2) QL (60 per 30 days) MO
JANUMET XR TB24 1000MG; 100MG $0(Tier 2) QL (30 per 30 days) MO
JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG $0(Tier 2) QL (60 per 30 days) MO
JANUVIA $0(Tier 2) QL (30 per 30 days) MO
JENTADUETO $0(Tier 2) QL (60 per 30 days) MO
JENTADUETO XR TB24 5MG; 1000MG $0(Tier 2) QL (30 per 30 days)
JENTADUETO XR TB24 2.5MG; 1000MG $0(Tier 2) QL (60 per 30 days)
metformin hcl er tb24 500mg, 750mg $0(Tier 1) MO
metformin hcl tabs $0(Tier 1) MO
miglitol $0(Tier 1)
nateglinide $0(Tier 1) QL (90 per 30 days) MO
pioglitazone hcl $0(Tier 1) QL (30 per 30 days) MO
pioglitazone hcl-glimepiride $0(Tier 1) QL (30 per 30 days) MO
pioglitazone hcl/metformin hcl $0(Tier 1) QL (90 per 30 days) MO
repaglinide $0(Tier 1) MO
RIOMET $0(Tier 2) MO
SYMLINPEN 120 $0(Tier 2) QL (11 per 28 days) PA
SYMLINPEN 60 $0(Tier 2) QL (6 per 30 days) PA
TRADJENTA $0(Tier 2) QL (30 per 30 days) MO
TRULICITY $0(Tier 2) QL (2 per 28 days)
VICTOZA $0(Tier 2) QL (9 per 30 days)
Glycemic Agents
GLUCAGEN HYPOKIT $0(Tier 2)
PROGLYCEM $0(Tier 2) MO
Insulins
HUMALOG KWIKPEN INJ 200UNIT/ML $0(Tier 2)
HUMALOG KWIKPEN INJ 100UNIT/ML $0(Tier 2) MO
HUMALOG MIX 50/50 $0(Tier 2) MO
HUMALOG MIX 50/50 KWIKPEN $0(Tier 2) MO
HUMALOG MIX 75/25 $0(Tier 2) MO
31 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
HUMALOG MIX 75/25 KWIKPEN $0(Tier 2) MO
HUMALOG INJ 100UNIT/ML $0(Tier 2)
HUMALOG INJ 100UNIT/ML $0(Tier 2) MO
HUMULIN 70/30 $0(Tier 2) MO
HUMULIN 70/30 KWIKPEN $0(Tier 2) MO
HUMULIN N $0(Tier 2) MO
HUMULIN N KWIKPEN $0(Tier 2) MO
HUMULIN R $0(Tier 2) MO
HUMULIN R U-500 (CONCENTRATED) $0(Tier 2) MO
HUMULIN R U-500 KWIKPEN $0(Tier 2) MO
LANTUS $0(Tier 2) MO
LANTUS SOLOSTAR $0(Tier 2) MO
LEVEMIR $0(Tier 2) MO
LEVEMIR FLEXTOUCH $0(Tier 2) MO
TOUJEO SOLOSTAR $0(Tier 2) MO
TRESIBA FLEXTOUCH $0(Tier 2)
Blood Products/Modifiers/Volume Expanders
(Drugs used to Stop Bleeding, Replace Blood, or Break-Up a Clot)
Anticoagulants
ELIQUIS TABS 2.5MG $0(Tier 2) QL (60 per 30 days) MO
ELIQUIS TABS 5MG $0(Tier 2) QL (74 per 30 days) MO
enoxaparin sodium inj 40mg/0.4ml $0(Tier 1) QL (12 per 30 days)
enoxaparin sodium inj 60mg/0.6ml $0(Tier 1) QL (18 per 30 days)
enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml $0(Tier 1) QL (24 per 30 days)
enoxaparin sodium inj 100mg/ml, 150mg/ml $0(Tier 1) QL (30 per 30 days)
enoxaparin sodium inj 30mg/0.3ml $0(Tier 1) QL (9 per 30 days)
enoxaparin sodium inj 300mg/3ml $0(Tier 1) QL (90 per 30 days)
fondaparinux sodium inj 5mg/0.4ml $0(Tier 1) QL (12 per 30 days)
fondaparinux sodium inj 2.5mg/0.5ml $0(Tier 1) QL (15 per 30 days)
fondaparinux sodium inj 7.5mg/0.6ml $0(Tier 1) QL (18 per 30 days)
fondaparinux sodium inj 10mg/0.8ml $0(Tier 1) QL (24 per 30 days)
heparin sodium/d5w $0(Tier 1)
heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% $0(Tier 1)
heparin sodium/nacl 0.9% $0(Tier 1)
heparin sodium/sodium chloride 0.9% $0(Tier 1)
heparin sodium/sodium chloride 0.9% premix $0(Tier 1)
heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml,
2000unit/ml, 2500unit/ml, 5000unit/ml
$0(Tier 1)
jantoven $0(Tier 1) MO
PRADAXA CAPS 110MG $0(Tier 2) QL (60 per 30 days)
PRADAXA CAPS 150MG, 75MG $0(Tier 2) QL (60 per 30 days) MO
warfarin sodium tabs $0(Tier 1) MO
32 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
XARELTO STARTER PACK $0(Tier 2) QL (102 per 365 days)
MO
XARELTO TABS 10MG, 20MG $0(Tier 2) QL (30 per 30 days) MO
XARELTO TABS 15MG $0(Tier 2) QL (60 per 30 days) MO
Blood Formation Modifiers
anagrelide hydrochloride $0(Tier 1) MO
ARANESP ALBUMIN FREE $0(Tier 2) PA
LEUKINE INJ 250MCG $0(Tier 2) PA
NEULASTA $0(Tier 2) PA
NEUMEGA $0(Tier 2) PA MO
NEUPOGEN $0(Tier 2) PA
PROCRIT $0(Tier 2) PA
PROMACTA $0(Tier 2) QL (30 per 30 days) PA
ZARXIO $0(Tier 2) PA
Coagulants
tranexamic acid tabs $0(Tier 1)
tranexamic acid inj $0(Tier 1) PA
Platelet Modifying Agents
AGGRENOX $0(Tier 2) QL (60 per 30 days) MO
aspir-low $0(Tier 1) MC
aspirin adult low strength $0(Tier 1) MC
aspirin ec low dose $0(Tier 1) MC
aspirin ec tbec 81mg $0(Tier 1) MC
aspirin low dose $0(Tier 1) MC
aspirin/dipyridamole $0(Tier 1) QL (60 per 30 days)
aspirin chew 81mg $0(Tier 1) MC
aspirin tbec 81mg $0(Tier 1) MC
BRILINTA TABS 60MG $0(Tier 2) QL (60 per 30 days)
BRILINTA TABS 90MG $0(Tier 2) QL (60 per 30 days) MO
childrens aspirin $0(Tier 1) MC
cilostazol $0(Tier 1) MO
clopidogrel tabs 300mg $0(Tier 1) QL (1 per 30 days) MO
clopidogrel tabs 75mg $0(Tier 1) QL (30 per 30 days)
EFFIENT TABS 10MG $0(Tier 2) QL (36 per 30 days) MO
EFFIENT TABS 5MG $0(Tier 2) QL (42 per 30 days) MO
Cardiovascular Agents (Drugs that Affect the Heart and Blood Vessels)
Alpha-adrenergic Agonists
clonidine hcl tabs $0(Tier 1) MO
clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr $0(Tier 1) QL (4 per 28 days) MO
clonidine hcl ptwk 0.3mg/24hr $0(Tier 1) QL (8 per 28 days) MO
midodrine hcl $0(Tier 1)
Alpha-adrenergic Blocking Agents
33 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
DIBENZYLINE $0(Tier 2)
phenoxybenzamine hydrochloride $0(Tier 1)
prazosin hcl $0(Tier 1) MO
Angiotensin II Receptor Antagonists
BENICAR $0(Tier 2) QL (30 per 30 days) MO
BENICAR HCT $0(Tier 2) QL (30 per 30 days) MO
candesartan cilexetil $0(Tier 1) MO
candesartan cilexetil/hydrochlorothiazide $0(Tier 1) MO
ENTRESTO $0(Tier 2) QL (60 per 30 days) PA
irbesartan $0(Tier 1) MO
irbesartan/hydrochlorothiazide $0(Tier 1) MO
losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg,
25mg; 100mg
$0(Tier 1) QL (30 per 30 days) MO
losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg $0(Tier 1) QL (60 per 30 days) MO
losartan potassium tabs 100mg $0(Tier 1) QL (30 per 30 days) MO
losartan potassium tabs 50mg $0(Tier 1) QL (60 per 30 days) MO
losartan potassium tabs 25mg $0(Tier 1) QL (90 per 30 days) MO
telmisartan $0(Tier 1) QL (30 per 30 days) MO
telmisartan/amlodipine $0(Tier 1) QL (30 per 30 days) MO
telmisartan/hydrochlorothiazide $0(Tier 1) QL (30 per 30 days) MO
valsartan $0(Tier 1)
valsartan/hydrochlorothiazide $0(Tier 1) MO
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide $0(Tier 1) MO
benazepril hcl tabs $0(Tier 1) MO
captopril/hydrochlorothiazide $0(Tier 1) MO
captopril tabs $0(Tier 1) MO
enalapril maleate/hydrochlorothiazide $0(Tier 1) MO
enalapril maleate tabs $0(Tier 1) MO
fosinopril sodium $0(Tier 1) MO
fosinopril sodium/hydrochlorothiazide $0(Tier 1) MO
lisinopril $0(Tier 1) MO
lisinopril/hydrochlorothiazide $0(Tier 1) MO
moexipril hcl $0(Tier 1) MO
moexipril/hydrochlorothiazide $0(Tier 1) MO
perindopril erbumine $0(Tier 1) MO
quinapril hcl $0(Tier 1) MO
quinapril/hydrochlorothiazide $0(Tier 1) MO
ramipril $0(Tier 1) MO
trandolapril $0(Tier 1) MO
Antiarrhythmics
amiodarone hcl tabs $0(Tier 1) MO
34 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
amiodarone hcl inj 50mg/ml, 900mg/18ml $0(Tier 1)
dofetilide $0(Tier 1)
flecainide acetate $0(Tier 1) MO
lidocaine hcl inj 10mg/ml, 20mg/ml $0(Tier 1)
mexiletine hcl $0(Tier 1) MO
MULTAQ $0(Tier 2) QL (60 per 30 days) MO
pacerone $0(Tier 1) MO
propafenone hcl $0(Tier 1) MO
propafenone hcl er $0(Tier 1) MO
quinidine sulfate $0(Tier 1)
sorine $0(Tier 1) MO
sotalol hcl $0(Tier 1) MO
sotalol hcl (af) $0(Tier 1) MO
TIKOSYN $0(Tier 2) MO
Beta-adrenergic Blocking Agents
acebutolol hcl caps $0(Tier 1) MO
atenolol/chlorthalidone $0(Tier 1) MO
atenolol tabs $0(Tier 1) MO
betaxolol hcl tabs 10mg, 20mg $0(Tier 1) MO
bisoprolol fumarate $0(Tier 1) MO
bisoprolol fumarate/hydrochlorothiazide $0(Tier 1) MO
BYSTOLIC TABS 10MG $0(Tier 2) QL (120 per 30 days)
BYSTOLIC TABS 20MG $0(Tier 2) QL (60 per 30 days)
BYSTOLIC TABS 2.5MG, 5MG $0(Tier 2) QL (90 per 30 days)
BYVALSON $0(Tier 2) QL (30 per 30 days)
carvedilol $0(Tier 1) MO
COREG CR $0(Tier 2) MO
labetalol hcl inj, tabs $0(Tier 1) MO
metoprolol succinate er $0(Tier 1) MO
metoprolol tartrate inj $0(Tier 1) MO
metoprolol tartrate tabs 37.5mg, 75mg $0(Tier 1)
metoprolol tartrate tabs 100mg, 25mg, 50mg $0(Tier 1) MO
metoprolol/hydrochlorothiazide $0(Tier 1) MO
nadolol/bendroflumethiazide $0(Tier 1) MO
nadolol tabs $0(Tier 1) MO
pindolol $0(Tier 1) MO
propranolol hcl er $0(Tier 1) MO
propranolol hcl inj, oral soln, tabs $0(Tier 1) MO
propranolol/hydrochlorothiazide $0(Tier 1) MO
timolol maleate tabs 10mg, 20mg, 5mg $0(Tier 1) MO
Calcium Channel Blocking Agents
afeditab cr $0(Tier 1) MO
35 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
amlodipine besylate/benazepril hydrochloride $0(Tier 1) MO
amlodipine besylate/valsartan $0(Tier 1) MO
amlodipine besylate tabs $0(Tier 1) MO
amlodipine/valsartan/hctz $0(Tier 1) MO
cartia xt $0(Tier 1) MO
dilt-xr $0(Tier 1) MO
diltiazem cd $0(Tier 1) MO
diltiazem hcl cd $0(Tier 1) MO
diltiazem hcl er $0(Tier 1) MO
diltiazem hcl tabs $0(Tier 1) MO
diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml $0(Tier 1) MO
felodipine er $0(Tier 1) MO
isradipine $0(Tier 1) MO
matzim la $0(Tier 1) MO
nicardipine hcl caps, inj $0(Tier 1) MO
nifedical xl $0(Tier 1) MO
nifedipine er $0(Tier 1) MO
nimodipine caps $0(Tier 1) MO
nisoldipine $0(Tier 1) MO
nisoldipine er $0(Tier 1) MO
taztia xt $0(Tier 1) MO
verapamil hcl er $0(Tier 1) MO
verapamil hcl sr cp24 360mg $0(Tier 1) MO
verapamil hcl inj, tabs $0(Tier 1) MO
Cardiovascular Agents, Other
DEMSER $0(Tier 2)
digitek tabs 0.25mg $0(Tier 1) PA
digitek tabs 0.125mg $0(Tier 1) QL (30 per 30 days)
digoxin inj $0(Tier 1) PA
digoxin tabs 250mcg $0(Tier 1) PA MO
digoxin tabs 125mcg $0(Tier 1) QL (30 per 30 days) MO
digox tabs 250mcg $0(Tier 1) PA MO
digox tabs 125mcg $0(Tier 1) QL (30 per 30 days) MO
LANOXIN PEDIATRIC $0(Tier 2) PA
NORTHERA $0(Tier 2) QL (180 per 30 days) PA
pentoxifylline er $0(Tier 1) MO
RANEXA TB12 500MG $0(Tier 2) QL (120 per 30 days) ST
MO
RANEXA TB12 1000MG $0(Tier 2) QL (60 per 30 days) ST
MO
TEKTURNA $0(Tier 2) ST MO
TEKTURNA HCT $0(Tier 2) ST MO
36 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide sodium $0(Tier 1)
acetazolamide tabs $0(Tier 1) MO
Diuretics, Loop
bumetanide inj $0(Tier 1)
bumetanide tabs $0(Tier 1) MO
EDECRIN $0(Tier 2) MO
ethacrynate sodium $0(Tier 1)
ethacrynic acid tabs $0(Tier 1)
furosemide inj $0(Tier 1)
furosemide oral soln, tabs $0(Tier 1) MO
SODIUM EDECRIN $0(Tier 2)
torsemide tabs $0(Tier 1) MO
Diuretics, Potassium-sparing
amiloride hcl tabs $0(Tier 1) MO
amiloride/hydrochlorothiazide $0(Tier 1) MO
spironolactone/hydrochlorothiazide $0(Tier 1) MO
spironolactone tabs $0(Tier 1) MO
triamterene/hydrochlorothiazide $0(Tier 1) MO
Diuretics, Thiazide
chlorothiazide $0(Tier 1) MO
chlorothiazide sodium $0(Tier 1)
chlorthalidone tabs 25mg, 50mg $0(Tier 1) MO
hydrochlorothiazide caps, tabs $0(Tier 1) MO
indapamide $0(Tier 1) MO
metolazone $0(Tier 1) MO
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized $0(Tier 1) MO
fenofibrate caps $0(Tier 1)
fenofibrate tabs 145mg, 160mg, 48mg, 54mg $0(Tier 1) MO
fenofibric acid dr $0(Tier 1) MO
gemfibrozil tabs $0(Tier 1) MO
LIPOFEN $0(Tier 2)
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium $0(Tier 1) QL (30 per 30 days) MO
CRESTOR $0(Tier 2) QL (30 per 30 days) MO
fluvastatin caps 20mg $0(Tier 1) QL (30 per 30 days) MO
fluvastatin caps 40mg $0(Tier 1) QL (60 per 30 days) MO
lovastatin tabs 40mg $0(Tier 1) QL (60 per 30 days) MO
lovastatin tabs 10mg, 20mg $0(Tier 1) QL (90 per 30 days) MO
pravastatin sodium tabs 80mg $0(Tier 1) QL (30 per 30 days) MO
pravastatin sodium tabs 40mg $0(Tier 1) QL (60 per 30 days) MO
37 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
pravastatin sodium tabs 10mg, 20mg $0(Tier 1) QL (90 per 30 days) MO
rosuvastatin calcium $0(Tier 1) QL (30 per 30 days) PA
simvastatin tabs 20mg, 40mg, 80mg $0(Tier 1) QL (30 per 30 days) MO
simvastatin tabs 10mg, 5mg $0(Tier 1) QL (90 per 30 days) MO
Dyslipidemics, Other
cholestyramine light $0(Tier 1) MO
cholestyramine pack, powd $0(Tier 1) MO
colestipol hcl gran, tabs $0(Tier 1) MO
KYNAMRO $0(Tier 2) PA
niacin er tbcr 500mg $0(Tier 1) QL (30 per 30 days) MO
niacin er tbcr 1000mg, 750mg $0(Tier 1) QL (60 per 30 days) MO
niacin tabs 100mg, 250mg, 500mg, 50mg $0(Tier 1) MC
niacin tbcr 500mg $0(Tier 1) MC
niacor $0(Tier 1) MO
omega-3-acid ethyl esters $0(Tier 1) QL (120 per 30 days) MO
prevalite $0(Tier 1) MO
REPATHA $0(Tier 2) QL (3 per 30 days) PA
REPATHA PUSHTRONEX SYSTEM $0(Tier 2) QL (3.5 per 30 days) PA
REPATHA SURECLICK $0(Tier 2) QL (3 per 30 days) PA
VASCEPA CAPS 1GM $0(Tier 2) QL (120 per 30 days) MO
VASCEPA CAPS 0.5GM $0(Tier 2) QL (240 per 30 days)
WELCHOL $0(Tier 2)
ZETIA $0(Tier 2) QL (30 per 30 days) MO
Vasodilators, Direct-acting Arterial/Venous
BIDIL $0(Tier 2) QL (180 per 30 days)
isosorbide dinitrate er $0(Tier 1) MO
isosorbide dinitrate tabs $0(Tier 1) MO
isosorbide mononitrate $0(Tier 1) MO
isosorbide mononitrate er $0(Tier 1) MO
minitran $0(Tier 1) MO
nitroglycerin lingual soln $0(Tier 1)
nitroglycerin transdermal $0(Tier 1) MO
nitroglycerin inj, subl $0(Tier 1)
NITROSTAT $0(Tier 2) MO
Vasodilators, Direct-acting Arterial
hydralazine hcl inj $0(Tier 1)
hydralazine hcl tabs $0(Tier 1) MO
minoxidil tabs $0(Tier 1) MO
Central Nervous System Agents (Drugs that Affect the Nervous System)
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine/dextroamphetamine cp24 $0(Tier 1) QL (60 per 30 days) MO
amphetamine/dextroamphetamine tabs $0(Tier 1) QL (90 per 30 days) MO
38 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
dextroamphetamine sulfate er cp24 15mg $0(Tier 1) QL (120 per 30 days) MO
dextroamphetamine sulfate er cp24 10mg, 5mg $0(Tier 1) QL (90 per 30 days) MO
dextroamphetamine sulfate soln $0(Tier 1) QL (1800 per 30 days)
dextroamphetamine sulfate tabs 10mg $0(Tier 1) QL (180 per 30 days) MO
dextroamphetamine sulfate tabs 5mg $0(Tier 1) QL (90 per 30 days) MO
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
clonidine hcl er $0(Tier 1)
dexmethylphenidate hcl $0(Tier 1) QL (60 per 30 days) MO
metadate er $0(Tier 1) QL (90 per 30 days)
methylphenidate hcl er tbcr 10mg $0(Tier 1) QL (180 per 30 days) MO
methylphenidate hcl er tbcr 20mg $0(Tier 1) QL (90 per 30 days) MO
methylphenidate hcl sr $0(Tier 1) QL (90 per 30 days) MO
methylphenidate hcl tabs $0(Tier 1) QL (90 per 30 days) MO
STRATTERA $0(Tier 2) MO
Central Nervous System, Other
HETLIOZ $0(Tier 2) QL (30 per 30 days) PA
NUEDEXTA $0(Tier 2)
riluzole $0(Tier 1)
tetrabenazine tabs 25mg $0(Tier 1) QL (120 per 30 days) PA
tetrabenazine tabs 12.5mg $0(Tier 1) QL (90 per 30 days) PA
XENAZINE TABS 25MG $0(Tier 2) QL (120 per 30 days) PA
XENAZINE TABS 12.5MG $0(Tier 2) QL (90 per 30 days) PA
Multiple Sclerosis Agents
AMPYRA $0(Tier 2) QL (60 per 30 days) PA
AVONEX $0(Tier 2) QL (4 per 28 days)
AVONEX PEN $0(Tier 2) QL (4 per 28 days)
COPAXONE INJ 40MG/ML $0(Tier 2)
glatopa $0(Tier 1) QL (30 per 30 days)
REBIF $0(Tier 2) QL (6 per 28 days)
REBIF REBIDOSE $0(Tier 2) QL (6 per 28 days)
REBIF REBIDOSE TITRATION PACK $0(Tier 2) QL (4.2 per 28 days)
REBIF TITRATION PACK $0(Tier 2) QL (4.2 per 28 days)
TYSABRI $0(Tier 2) PA
Dental and Oral Agents (Drugs that Relieve or Prevent Problems of the Mouth)
Dental and Oral Agents
chlorhexidine gluconate soln $0(Tier 1)
oralone $0(Tier 1)
paroex $0(Tier 1)
periogard $0(Tier 1)
pilocarpine hcl tabs 7.5mg $0(Tier 1) MO
pilocarpine hydrochloride $0(Tier 1)
39 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
triamcinolone acetonide pste 0.1% $0(Tier 1)
triamcinolone in orabase $0(Tier 1)
Dermatological Agents (Drugs used for Skin Problems)
Dermatological Agents
acitretin $0(Tier 1) PA
acne medication 10 $0(Tier 1) MC
acne medication 5 gel $0(Tier 1) MC
ammonium lactate crea, lotn $0(Tier 1)
amnesteem $0(Tier 1)
benzoyl peroxide foam, gel $0(Tier 1) MC
blue gel $0(Tier 1) MC
calcipotriene $0(Tier 1) QL (120 per 30 days)
calcitrene $0(Tier 1) QL (120 per 30 days)
calcitriol oint 3mcg/gm $0(Tier 1)
CARAC $0(Tier 2)
claravis $0(Tier 1)
coats aloe creme $0(Tier 1) MC
coats aloe gelly $0(Tier 1) MC
coats aloe liniment $0(Tier 1) MC
coats aloe moisturizing lotion $0(Tier 1) MC
curity gauze pads 2"x2" $0(Tier 1)
dibucaine $0(Tier 1) MC
diclofenac sodium gel 1% $0(Tier 1) QL (1000 per 30 days) PA
diclofenac sodium transdermal soln 1.5% $0(Tier 1)
doxepin hydrochloride $0(Tier 1)
DR SMITHS DIAPER $0(Tier 1) MC
dr smiths diaper rash spray $0(Tier 1) MC
dr smiths rash + skin aero $0(Tier 1) MC
ELIDEL $0(Tier 2)
erythromycin/benzoyl peroxide $0(Tier 1)
fluorouracil crea 0.5% $0(Tier 1)
fluorouracil crea 5% $0(Tier 1) MO
fluorouracil external soln 2%, 5% $0(Tier 1) MO
hemorrhoidal supp 88.7%; 0.25% $0(Tier 1) MC
imiquimod crea $0(Tier 1)
lidocaine crea 5% $0(Tier 1) MC
major-prep hemorrhoidal $0(Tier 1) MC
medicated body powder powd 0.15% $0(Tier 1) MC
methoxsalen caps $0(Tier 1)
myorisan $0(Tier 1)
PICATO $0(Tier 2) ST
podofilox soln $0(Tier 1)
40 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
PRUDOXIN $0(Tier 2)
REGRANEX $0(Tier 2) PA
SANTYL $0(Tier 2)
selenium sulfide lotn $0(Tier 1)
tacrolimus oint 0.03%, 0.1% $0(Tier 1)
TAZORAC GEL $0(Tier 2) QL (100 per 30 days)
TAZORAC CREA $0(Tier 2) QL (120 per 30 days)
THERA-GESIC CREA 1%; 15% $0(Tier 1) MC
tretinoin microsphere $0(Tier 1) PA
tretinoin microsphere pump gel 0.1% $0(Tier 1) PA
tretinoin microsphere pump gel 0.04% $0(Tier 1) PA MO
tretinoin crea 0.025%, 0.05%, 0.1% $0(Tier 1) QL (45 per 30 days) PA
MO
tretinoin gel 0.01% $0(Tier 1) QL (45 per 30 days) PA
tretinoin gel 0.025% $0(Tier 1) QL (45 per 30 days) PA
MO
trixaicin $0(Tier 1) MC
trixaicin hp $0(Tier 1) MC
UVADEX $0(Tier 2) B/D
VECTICAL $0(Tier 2)
vitamin a & d oint 15.5%; 53.4% $0(Tier 1) MC
VOLTAREN $0(Tier 2) QL (1000 per 30 days) ST
white petrolatum gel $0(Tier 1) MC
zenatane $0(Tier 1)
zinc oxide oint 20% $0(Tier 1) MC
ZONALON $0(Tier 2)
ZYCLARA $0(Tier 2)
ZYCLARA PUMP CREA 2.5% $0(Tier 2)
Enzyme Replacement/Modifiers (Drugs used to Replace or Change Bodily Enzymes)
Enzyme Replacement/Modifiers
ADAGEN $0(Tier 2) PA MO
ALDURAZYME $0(Tier 2) PA
BUPHENYL TABS $0(Tier 2) MO
CEREZYME $0(Tier 2) B/D
CREON $0(Tier 2) MO
CYSTADANE $0(Tier 2)
CYSTAGON $0(Tier 2)
ELAPRASE $0(Tier 2) PA
FABRAZYME $0(Tier 2) B/D
KUVAN $0(Tier 2) PA
LUMIZYME $0(Tier 2) PA
NAGLAZYME $0(Tier 2) PA
41 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
ORFADIN SUSP $0(Tier 2)
ORFADIN CAPS 20MG $0(Tier 2)
ORFADIN CAPS 10MG, 2MG, 5MG $0(Tier 2) MO
PANCRELIPASE $0(Tier 2) MO
sodium phenylbutyrate powd $0(Tier 1)
VPRIV $0(Tier 2) PA
ZAVESCA $0(Tier 2)
ZENPEP $0(Tier 2) MO
Gastrointestinal Agents (Drugs that Treat Issues of the Stomach, Bowels, and Gallbladder)
Antispasmodics, Gastrointestinal
anaspaz $0(Tier 1)
atropine sulfate inj 0.05mg/ml, 0.1mg/ml, 0.4mg/ml, 1mg/ml $0(Tier 1)
dicyclomine hcl caps, soln, tabs $0(Tier 1)
ed-spaz $0(Tier 1)
glycopyrrolate tabs $0(Tier 1)
glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml $0(Tier 1)
hyoscyamine sulfate odt $0(Tier 1)
hyoscyamine sulfate elix, subl, tabs, tbdp $0(Tier 1)
hyosyne elix $0(Tier 1)
methscopolamine bromide $0(Tier 1)
nulev $0(Tier 1)
oscimin $0(Tier 1)
propantheline bromide $0(Tier 1)
symax-sl $0(Tier 1)
Gastrointestinal Agents, Other
acid gone susp $0(Tier 1) MC
acid reducer maximum strength $0(Tier 1) MC
ACTIDOSE/SORBITOL LIQD 50GM/240ML; 0 $0(Tier 1) MC
almacone $0(Tier 1) MC
almacone double strength $0(Tier 1) MC
aluminum hydroxide $0(Tier 1) MC
antacid calcium extra st rength $0(Tier 1) MC
antacid calcium regular strength $0(Tier 1) MC
antacid extra strength $0(Tier 1) MC
antacid maximum strength $0(Tier 1) MC
antacid plus anti-gas relief $0(Tier 1) MC
anti-diarrheal tabs $0(Tier 1) MC
anti-nausea $0(Tier 1) MC
anu-med $0(Tier 1) MC
bisacodyl ec tbec 5mg $0(Tier 1) MC
biscolax $0(Tier 1) MC
bismatrol $0(Tier 1) MC
42 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
bismatrol maximum strength $0(Tier 1) MC
cal-gest antacid $0(Tier 1) MC
calcium antacid $0(Tier 1) MC
calcium antacid extra strength $0(Tier 1) MC
chewable antacid $0(Tier 1) MC
cromolyn sodium conc 100mg/5ml $0(Tier 1) MO
diocto $0(Tier 1) MC
diphenoxylate/atropine $0(Tier 1)
docqlace caps 100mg $0(Tier 1) MC
docu $0(Tier 1) MC
docusol kids $0(Tier 1) MC
dok caps 100mg, 250mg $0(Tier 1) MC
dok tabs 100mg $0(Tier 1) MC
enemeez mini $0(Tier 1) MC
enemeez plus $0(Tier 1) MC
fiber tabs $0(Tier 1) MC
fiber-lax $0(Tier 1) MC
FLEET PEDIATRIC $0(Tier 1) MC
gas relief $0(Tier 1) MC
gas relief extra strength caps $0(Tier 1) MC
gas relief maximum strength $0(Tier 1) MC
GATTEX $0(Tier 2) PA
gnp antacid anti-gas $0(Tier 1) MC
gnp masanti maximum strength $0(Tier 1) MC
gnp masanti regular strength $0(Tier 1) MC
infants gas relief susp 20mg/0.3ml $0(Tier 1) MC
infants simethicone $0(Tier 1) MC
kao-tin caps 240mg $0(Tier 1) MC
kao-tin susp 262mg/15ml $0(Tier 1) MC
laxative $0(Tier 1) MC
loperamide hcl caps $0(Tier 1)
loperamide hcl liqd, susp $0(Tier 1) MC
magnesium oxide tabs 241.3mg, 400mg, 420mg $0(Tier 1) MC
magnesium caps 500mg $0(Tier 1) MC
magnesium tabs 500mg $0(Tier 1) MC
metoclopramide hcl inj, oral soln $0(Tier 1)
metoclopramide hcl tabs $0(Tier 1) MO
mi-acid gas relief $0(Tier 1) MC
mi-acid maximum strength $0(Tier 1) MC
mi-acid susp $0(Tier 1) MC
milk of magnesia concentrate $0(Tier 1) MC
milk of magnesia susp 400mg/5ml, 7.75% $0(Tier 1) MC
43 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
mintox maximum strength $0(Tier 1) MC
mytab gas $0(Tier 1) MC
mytab gas max str $0(Tier 1) MC
natural fiber therapy $0(Tier 1) MC
OSMOPREP $0(Tier 2)
peptic relief chew 262mg $0(Tier 1) MC
phillips tabs $0(Tier 1) MC
pink bismuth chew $0(Tier 1) MC
qc anti-diarrheal $0(Tier 1) MC
reguloid $0(Tier 1) MC
RELISTOR INJ 8MG/0.4ML $0(Tier 2) QL (12 per 30 days) PA
RELISTOR INJ 12MG/0.6ML $0(Tier 2) QL (18 per 30 days) PA
rulox $0(Tier 1) MC
senexon $0(Tier 1) MC
senna lax $0(Tier 1) MC
senna syrp 8.8mg/5ml $0(Tier 1) MC
senna tabs 8.6mg $0(Tier 1) MC
simethicone caps 180mg $0(Tier 1) MC
simethicone susp $0(Tier 1) MC
sm antacid anti-gas $0(Tier 1) MC
sm antacid/antigas $0(Tier 1) MC
sm anti-diarrheal tabs $0(Tier 1) MC
sodium bicarbonate tabs 325mg, 650mg $0(Tier 1) MC
stimulant laxative $0(Tier 1) MC
stool softener extra strength $0(Tier 1) MC
stool softener laxative dc $0(Tier 1) MC
stool softener caps 100mg $0(Tier 1) MC
th antacid regular strength $0(Tier 1) MC
ursodiol caps $0(Tier 1)
ursodiol tabs $0(Tier 1) MO
Histamine2 (H2) Receptor Antagonists
cimetidine hcl $0(Tier 1) MO
cimetidine tabs $0(Tier 1) MO
famotidine premixed $0(Tier 1)
famotidine inj $0(Tier 1)
famotidine tabs 10mg $0(Tier 1) MC
famotidine tabs 20mg, 40mg $0(Tier 1) MO
nizatidine caps 150mg $0(Tier 1)
nizatidine caps 300mg $0(Tier 1) MO
ranitidine 150 maximum strength $0(Tier 1) MC
ranitidine 75 $0(Tier 1) MC
ranitidine hcl caps, syrp $0(Tier 1) MO
44 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
ranitidine hcl inj 150mg/6ml $0(Tier 1)
ranitidine hcl tabs 150mg $0(Tier 1)
ranitidine hcl tabs 300mg $0(Tier 1) MO
ranitidine maximum strength $0(Tier 1) MC
Irritable Bowel Syndrome Agents
alosetron hydrochloride $0(Tier 1) QL (60 per 30 days) PA
AMITIZA $0(Tier 2) QL (60 per 30 days) MO
LINZESS $0(Tier 2) QL (30 per 30 days)
Laxatives
bisacodyl ec tbec 5mg $0(Tier 1) MC
constulose $0(Tier 1) MO
cvs laxative dietary supplement $0(Tier 1) MC
doc-q-lax $0(Tier 1) MC
docqlace caps 100mg $0(Tier 1) MC
docusate sodium & senna stimulant laxative/stool softener $0(Tier 1) MC
docusol plus mini-enema $0(Tier 1) MC
dok plus $0(Tier 1) MC
dok caps 100mg, 250mg $0(Tier 1) MC
enema ready-to-use $0(Tier 1) MC
enulose $0(Tier 1) MO
fiber laxative caps $0(Tier 1) MC
gavilyte-c $0(Tier 1)
gavilyte-g $0(Tier 1)
gavilyte-n/flavor pack $0(Tier 1)
generlac $0(Tier 1) MO
gnp enema $0(Tier 1) MC
kao-tin caps 240mg $0(Tier 1) MC
lactulose soln $0(Tier 1) MO
milk of magnesia susp 400mg/5ml $0(Tier 1) MC
MOVIPREP $0(Tier 2)
peg 3350/electrolytes $0(Tier 1)
peg 3350 pack $0(Tier 1) MC
peg-3350/electrolytes $0(Tier 1)
peg-3350/nacl/na bicarbonate/kcl $0(Tier 1)
peg3350 $0(Tier 1) MC
polyethylene glycol 3350 powd $0(Tier 1)
sani-supp adult $0(Tier 1) MC
sani-supp pediatric $0(Tier 1) MC
senna plus $0(Tier 1) MC
senna-lax $0(Tier 1) MC
sennalax-s $0(Tier 1) MC
senna tabs 8.6mg $0(Tier 1) MC
45 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
stool softener caps 100mg, 240mg $0(Tier 1) MC
SUPREP BOWEL PREP $0(Tier 2)
trilyte $0(Tier 1)
Protectants
CARAFATE SUSP $0(Tier 2) MO
misoprostol $0(Tier 1) MO
sucralfate tabs $0(Tier 1) MO
Proton Pump Inhibitors
DEXILANT $0(Tier 2) QL (60 per 30 days) ST
esomeprazole magnesium $0(Tier 1) QL (60 per 30 days)
esomeprazole sodium $0(Tier 1)
gnp omeprazole $0(Tier 1) MC
heartburn treatment 24 hour $0(Tier 1) MC
lansoprazole cpdr 15mg $0(Tier 1) MC
lansoprazole cpdr 15mg, 30mg $0(Tier 1) MO
omeprazole magnesium $0(Tier 1) MC
omeprazole tbec $0(Tier 1) MC
omeprazole cpdr $0(Tier 1) MO
pantoprazole sodium tbec $0(Tier 1) MO
Genitourinary Agents (Drugs that Treat Problems of the Urinary Tract)
Antispasmodics, Urinary
flavoxate hcl $0(Tier 1) MO
oxybutynin chloride er tb24 5mg $0(Tier 1) QL (30 per 30 days) MO
oxybutynin chloride er tb24 10mg, 15mg $0(Tier 1) QL (60 per 30 days) MO
oxybutynin chloride syrp $0(Tier 1)
oxybutynin chloride tabs $0(Tier 1) MO
tolterodine tartrate $0(Tier 1)
VESICARE $0(Tier 2) QL (30 per 30 days) MO
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er $0(Tier 1) QL (30 per 30 days)
AVODART $0(Tier 2) MO
doxazosin $0(Tier 1) QL (30 per 30 days) MO
doxazosin mesylate tabs 1mg, 2mg $0(Tier 1) QL (30 per 30 days) MO
doxazosin mesylate tabs 8mg $0(Tier 1) QL (60 per 30 days) MO
dutasteride $0(Tier 1)
dutasteride/tamsulosin hydrochloride $0(Tier 1)
finasteride tabs 5mg $0(Tier 1) QL (30 per 30 days) MO
JALYN $0(Tier 2) MO
tamsulosin hcl $0(Tier 1) MO
terazosin hcl caps 1mg, 5mg $0(Tier 1) QL (30 per 30 days) MO
terazosin hcl caps 10mg, 2mg $0(Tier 1) QL (60 per 30 days) MO
Genitourinary Agents, Other
46 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
bethanechol chloride $0(Tier 1)
ELMIRON $0(Tier 2)
phenazopyridine hcl tabs 100mg, 200mg $0(Tier 1)
Phosphate Binders
AURYXIA $0(Tier 2) MO
calcium acetate caps $0(Tier 1) MO
calcium acetate tabs 667mg $0(Tier 1) MO
PHOSLYRA $0(Tier 2) MO
RENVELA PACK $0(Tier 2) QL (180 per 30 days) MO
RENVELA TABS $0(Tier 2) QL (540 per 30 days) MO
VELPHORO $0(Tier 2) MO
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
(Drugs that Control or Replace Hormones Associated with the Adrenal Gland)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort $0(Tier 1)
ala cort $0(Tier 1)
ALA SCALP $0(Tier 2)
alclometasone dipropionate $0(Tier 1)
amcinonide $0(Tier 1)
augmented betamethasone dipropionate $0(Tier 1)
betamethasone dipropionate crea, lotn, oint $0(Tier 1)
betamethasone valerate crea, foam, lotn, oint $0(Tier 1)
clobetasol propionate e $0(Tier 1)
clobetasol propionate emollient $0(Tier 1)
clobetasol propionate crea, foam, gel, oint, sham, soln $0(Tier 1)
clodan $0(Tier 1)
cormax scalp application $0(Tier 1)
cortisone acetate tabs $0(Tier 1)
DEPO-MEDROL INJ 20MG/ML $0(Tier 2)
desonide lotn, oint $0(Tier 1)
desoximetasone crea, gel $0(Tier 1)
desoximetasone oint 0.25% $0(Tier 1)
dexamethasone intensol $0(Tier 1)
dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml,
20mg/5ml, 4mg/ml
$0(Tier 1)
dexamethasone elix, soln, tabs $0(Tier 1)
diflorasone diacetate $0(Tier 1)
fludrocortisone acetate tabs $0(Tier 1) MO
fluocinolone acetonide body $0(Tier 1)
fluocinolone acetonide ear drops $0(Tier 1)
fluocinolone acetonide scalp $0(Tier 1)
fluocinolone acetonide crea 0.01%, 0.025% $0(Tier 1)
47 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
fluocinolone acetonide oint 0.025% $0(Tier 1)
fluocinolone acetonide soln 0.01% $0(Tier 1)
fluocinonide-e $0(Tier 1)
fluocinonide crea, gel, oint, soln $0(Tier 1)
fluticasone propionate crea 0.05% $0(Tier 1)
fluticasone propionate oint 0.005% $0(Tier 1)
halobetasol propionate $0(Tier 1)
hydro skin maximum strength $0(Tier 1) MC
hydrocortisone butyrate (lipid) $0(Tier 1)
hydrocortisone butyrate (lipophilic) $0(Tier 1)
hydrocortisone butyrate crea, oint, soln $0(Tier 1)
hydrocortisone in absorbase $0(Tier 1)
hydrocortisone valerate $0(Tier 1)
hydrocortisone/aloe crea 0; 1% $0(Tier 1) MC
hydrocortisone crea 1%, 2.5% $0(Tier 1)
hydrocortisone crea 0.5%, 1% $0(Tier 1) MC
hydrocortisone lotn 2.5% $0(Tier 1)
hydrocortisone oint 1%, 2.5% $0(Tier 1)
hydrocortisone oint 0.5%, 1% $0(Tier 1) MC
hydrocortisone tabs 10mg, 20mg, 5mg $0(Tier 1)
hydroskin $0(Tier 1) MC
MEDROL TABS 2MG $0(Tier 2)
methylprednisolone acetate inj $0(Tier 1)
methylprednisolone dose pack $0(Tier 1)
methylprednisolone sodiumsuccinate inj 125mg, 40mg $0(Tier 1)
methylprednisolone tabs $0(Tier 1)
mometasone furoate crea, oint, soln $0(Tier 1)
prednicarbate oint $0(Tier 1)
prednisolone sodium phosphate oral soln 15mg/5ml, 5mg/5ml $0(Tier 1)
prednisolone sodium phosphate oral soln 25mg/5ml $0(Tier 1) MO
prednisolone soln $0(Tier 1)
prednisone intensol $0(Tier 1)
prednisone soln, tabs, tbpk $0(Tier 1)
procto-med hc $0(Tier 1)
procto-pak $0(Tier 1)
proctosol hc $0(Tier 1)
proctozone-hc $0(Tier 1)
SOLU-CORTEF $0(Tier 2)
TEXACORT $0(Tier 2)
triamcinolone acetonide crea 0.025%, 0.1%, 0.5% $0(Tier 1)
triamcinolone acetonide lotn 0.025%, 0.1% $0(Tier 1)
triamcinolone acetonide oint 0.025%, 0.1%, 0.5% $0(Tier 1)
48 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
trianex $0(Tier 1)
triderm $0(Tier 1)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
(Drugs that Control or Replace Hormones Associated with the Pituitary Gland)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
CHORIONIC GONADOTROPIN $0(Tier 2) PA
desmopressin acetate inj $0(Tier 1)
desmopressin acetate tabs $0(Tier 1) MO
desmopressin acetate nasal soln 0.01% $0(Tier 1)
desmopressin acetate nasal soln 0.01% $0(Tier 1) MO
INCRELEX $0(Tier 2) PA
NOVAREL $0(Tier 2) PA
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL $0(Tier 2) PA
SAIZEN $0(Tier 2) PA MO
SAIZEN CLICK.EASY $0(Tier 2) PA MO
STIMATE $0(Tier 2) MO
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
(Drugs that Control Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM $0(Tier 2) QL (120 per 30 days) PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
(Drugs that Control or Replace Sex Hormones)
Anabolic Steroids
ANADROL-50 $0(Tier 2) PA
oxandrolone tabs 2.5mg $0(Tier 1) QL (120 per 30 days) PA
oxandrolone tabs 10mg $0(Tier 1) QL (60 per 30 days) PA
Androgens
ANDROGEL $0(Tier 2) PA MO
ANDROGEL PUMP GEL 1.62% $0(Tier 2) PA MO
ANDROXY $0(Tier 2) PA
danazol caps $0(Tier 1)
TESTIM $0(Tier 2) PA MO
testosterone cypionate inj $0(Tier 1) PA
testosterone enanthate inj $0(Tier 1) PA
testosterone pump $0(Tier 1) PA
testosterone gel 25mg/2.5gm $0(Tier 1) PA
Estrogens
ALORA $0(Tier 2) QL (8 per 28 days) PA
MO
altavera $0(Tier 1) MO
alyacen 1/35 $0(Tier 1) MO
49 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
alyacen 7/7/7 $0(Tier 1) MO
amethia $0(Tier 1) MO
amethia lo $0(Tier 1) MO
apri $0(Tier 1) MO
aranelle $0(Tier 1) MO
aubra $0(Tier 1) MO
aviane $0(Tier 1) MO
azurette $0(Tier 1) MO
balziva $0(Tier 1) MO
bekyree $0(Tier 1)
blisovi fe 1.5/30 $0(Tier 1)
blisovi fe 1/20 $0(Tier 1)
briellyn $0(Tier 1) MO
caziant $0(Tier 1) MO
chateal $0(Tier 1) MO
cryselle-28 $0(Tier 1) MO
cyclafem 1/35 $0(Tier 1) MO
cyclafem 7/7/7 $0(Tier 1) MO
cyred $0(Tier 1)
dasetta 1/35 $0(Tier 1) MO
dasetta 7/7/7 $0(Tier 1) MO
DELESTROGEN $0(Tier 2) MO
delyla $0(Tier 1) MO
DEPO-ESTRADIOL $0(Tier 2) MO
desogestrel/ethinyl estradiol $0(Tier 1) MO
elinest $0(Tier 1) MO
emoquette $0(Tier 1) MO
enpresse-28 $0(Tier 1) MO
enskyce $0(Tier 1) MO
estarylla $0(Tier 1) MO
estradiol valerate inj $0(Tier 1) MO
estradiol/norethindrone acetate $0(Tier 1) PA MO
estradiol tabs $0(Tier 1) PA MO
estradiol ptwk $0(Tier 1) QL (4 per 28 days) PA
MO
estradiol pttw $0(Tier 1) QL (8 per 28 days) PA
MO
ESTRING $0(Tier 2) QL (1 per 90 days) MO
falmina $0(Tier 1) MO
FEMRING $0(Tier 2) MO
gildagia $0(Tier 1) MO
gildess 1.5/30 $0(Tier 1) MO
50 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
gildess 1/20 $0(Tier 1) MO
gildess fe 1.5/30 $0(Tier 1) MO
gildess fe 1/20 $0(Tier 1) MO
introvale $0(Tier 1) MO
juleber $0(Tier 1)
junel 1.5/30 $0(Tier 1) MO
junel 1/20 $0(Tier 1) MO
junel fe 1.5/30 $0(Tier 1) MO
junel fe 1/20 $0(Tier 1) MO
kariva $0(Tier 1) MO
kelnor 1/35 $0(Tier 1) MO
kimidess $0(Tier 1)
kurvelo $0(Tier 1) MO
larin 1.5/30 $0(Tier 1) MO
larin 1/20 $0(Tier 1) MO
larin fe 1.5/30 $0(Tier 1) MO
larin fe 1/20 $0(Tier 1) MO
larissia $0(Tier 1)
lessina $0(Tier 1) MO
levonest $0(Tier 1) MO
levonorgestrel and ethinyl estradiol tabs 0; 0 $0(Tier 1) MO
levonorgestrel/ethinyl estradiol tabs 0; 0 $0(Tier 1)
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 20mcg;
0.1mg
$0(Tier 1) MO
levora 0.15/30-28 $0(Tier 1) MO
lopreeza $0(Tier 1) PA MO
low-ogestrel $0(Tier 1) MO
lutera $0(Tier 1) MO
marlissa $0(Tier 1) MO
MENEST $0(Tier 2) PA MO
MENOSTAR $0(Tier 2) QL (4 per 28 days) PA
MO
microgestin 1.5/30 $0(Tier 1) MO
microgestin 1/20 $0(Tier 1) MO
microgestin fe $0(Tier 1) MO
microgestin fe 1.5/30 $0(Tier 1) MO
mimvey $0(Tier 1) PA MO
mimvey lo $0(Tier 1) PA MO
MINIVELLE $0(Tier 2) QL (8 per 28 days) PA
MO
mono-linyah $0(Tier 1) MO
myzilra $0(Tier 1) MO
51 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
necon 0.5/35-28 $0(Tier 1) MO
necon 1/35 $0(Tier 1) MO
necon 1/50-28 $0(Tier 1)
necon 10/11-28 $0(Tier 1) MO
necon 7/7/7 $0(Tier 1) MO
norethindrone acetate/ethinyl estradiol/ferrous fumarate $0(Tier 1) MO
norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg $0(Tier 1) MO
norgestimate/ethinyl estradiol $0(Tier 1) MO
nortrel 0.5/35 (28) $0(Tier 1) MO
nortrel 1/35 $0(Tier 1) MO
nortrel 7/7/7 $0(Tier 1) MO
ogestrel $0(Tier 1) MO
orsythia $0(Tier 1) MO
philith $0(Tier 1) MO
pimtrea $0(Tier 1) MO
pirmella 1/35 $0(Tier 1) MO
pirmella 7/7/7 $0(Tier 1) MO
portia-28 $0(Tier 1) MO
PREMARIN CREA, INJ $0(Tier 2) MO
PREMARIN TABS $0(Tier 2) QL (30 per 30 days) PA
MO
previfem $0(Tier 1) MO
quasense $0(Tier 1) MO
reclipsen $0(Tier 1) MO
setlakin $0(Tier 1)
sprintec 28 $0(Tier 1) MO
sronyx $0(Tier 1) MO
tarina fe 1/20 $0(Tier 1) MO
tilia fe $0(Tier 1) MO
tri-estarylla $0(Tier 1) MO
tri-legest fe $0(Tier 1) MO
tri-linyah $0(Tier 1) MO
tri-previfem $0(Tier 1) MO
tri-sprintec $0(Tier 1) MO
trivora-28 $0(Tier 1) MO
VAGIFEM $0(Tier 2)
velivet $0(Tier 1) MO
vienva $0(Tier 1)
viorele $0(Tier 1) MO
vyfemla $0(Tier 1) MO
wera $0(Tier 1) MO
zenchent $0(Tier 1) MO
52 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
zovia 1/35e $0(Tier 1) MO
zovia 1/50e $0(Tier 1) MO
Progesterone Agonists/Antagonists
ELLA $0(Tier 2)
Progestins
camila $0(Tier 1) MO
deblitane $0(Tier 1)
DEPO-PROVERA $0(Tier 2)
econtra ez $0(Tier 1) MC
errin $0(Tier 1) MO
fallback solo $0(Tier 1) MC
heather $0(Tier 1)
hydroxyprogesterone caproate inj $0(Tier 1)
jencycla $0(Tier 1)
lyza $0(Tier 1) MO
MAKENA $0(Tier 2)
medroxyprogesterone acetate tabs $0(Tier 1) MO
medroxyprogesterone acetate inj $0(Tier 1) QL (1 per 90 days)
megestrol acetate tabs $0(Tier 1) PA
megestrol acetate susp 40mg/ml $0(Tier 1) PA
my way $0(Tier 1) MC
next choice one dose $0(Tier 1) MC
norethindrone acetate tabs $0(Tier 1) MO
norethindrone tabs $0(Tier 1)
norlyroc $0(Tier 1)
opcicon one-step $0(Tier 1) MC
progesterone caps $0(Tier 1) MO
sharobel $0(Tier 1)
Selective Estrogen Receptor Modifying Agents
raloxifene hydrochloride $0(Tier 1) QL (30 per 30 days) MO
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
(Drugs that Replace Thyroid Hormone)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium tabs $0(Tier 1) MO
LEVOXYL $0(Tier 2) MO
liothyronine sodium inj $0(Tier 1)
liothyronine sodium tabs $0(Tier 1) MO
SYNTHROID $0(Tier 2) MO
THYROLAR-1 $0(Tier 2) MO
THYROLAR-1/2 $0(Tier 2) MO
THYROLAR-1/4 $0(Tier 2) MO
THYROLAR-2 $0(Tier 2) MO
53 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
THYROLAR-3 $0(Tier 2) MO
UNITHROID $0(Tier 2)
Hormonal Agents, Suppressant (Adrenal)
(Drugs that Decrease Levels of Hormones Associated with the Adrenal Glands)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN $0(Tier 2)
Hormonal Agents, Suppressant (Parathyroid)
(Drugs that Lower Parathyroid Hormone Levels)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 90MG $0(Tier 2) QL (120 per 30 days) MO
SENSIPAR TABS 30MG, 60MG $0(Tier 2) QL (60 per 30 days) MO
Hormonal Agents, Suppressant (Pituitary)
(Drugs that Decrease Thyroid Stimulating Hormone Production)
Hormonal Agents, Suppressant (Pituitary)
cabergoline $0(Tier 1)
ELIGARD INJ 30MG $0(Tier 2) QL (1 per 120 days) PA
ELIGARD INJ 45MG $0(Tier 2) QL (1 per 180 days) PA
ELIGARD INJ 7.5MG $0(Tier 2) QL (1 per 30 days) PA
ELIGARD INJ 22.5MG $0(Tier 2) QL (1 per 90 days) PA
FIRMAGON INJ 80MG $0(Tier 2) QL (4 per 28 days) B/D
FIRMAGON INJ 120MG $0(Tier 2) QL (6 per 365 days) B/D
leuprolide acetate inj $0(Tier 1) QL (5.6 per 28 days) PA
LUPRON DEPOT-PED $0(Tier 2) QL (1 per 30 days) PA
LUPRON DEPOT INJ 30MG $0(Tier 2) QL (1 per 112 days) PA
LUPRON DEPOT INJ 45MG $0(Tier 2) QL (1 per 168 days) PA
LUPRON DEPOT INJ 3.75MG, 7.5MG $0(Tier 2) QL (1 per 30 days) PA
LUPRON DEPOT INJ 22.5MG $0(Tier 2) QL (1 per 84 days) PA
LUPRON DEPOT INJ 11.25MG $0(Tier 2) QL (1 per 90 days) PA
octreotide acetate $0(Tier 1) PA
SANDOSTATIN LAR DEPOT $0(Tier 2) PA
SIGNIFOR $0(Tier 2) PA
SOMATULINE DEPOT $0(Tier 2) PA
SOMAVERT INJ 25MG, 30MG $0(Tier 2) QL (30 per 30 days) PA
SOMAVERT INJ 15MG, 20MG $0(Tier 2) QL (60 per 30 days) PA
SOMAVERT INJ 10MG $0(Tier 2) QL (90 per 30 days) PA
SYNAREL $0(Tier 2) PA MO
TRELSTAR MIXJECT INJ 22.5MG $0(Tier 2) QL (2 per 168 days) PA
TRELSTAR MIXJECT INJ 3.75MG $0(Tier 2) QL (2 per 28 days) PA
TRELSTAR MIXJECT INJ 11.25MG $0(Tier 2) QL (2 per 84 days) PA
TRELSTAR INJ 3.75MG $0(Tier 2) QL (2 per 28 days) PA
TRELSTAR INJ 11.25MG $0(Tier 2) QL (2 per 84 days) PA
54 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
Hormonal Agents, Suppressant (Thyroid)
(Drugs that Lower Thyroid Hormone Levels)
Antithyroid Agents
methimazole tabs $0(Tier 1) MO
propylthiouracil tabs $0(Tier 1) MO
Immunological Agents
(Drugs used for Prevention of Disease and Infection or can Affect the Immune System)
Angioedema (HAE) Agents
CINRYZE $0(Tier 2) PA
FIRAZYR $0(Tier 2) PA
Immune Suppressants
ASTAGRAF XL $0(Tier 2) PA MO
AZASAN $0(Tier 2) PA MO
azathioprine inj $0(Tier 1) PA
azathioprine tabs $0(Tier 1) PA MO
BENLYSTA $0(Tier 2) PA
CELLCEPT INTRAVENOUS $0(Tier 2) PA
cyclosporine modified $0(Tier 1) PA MO
cyclosporine inj $0(Tier 1) PA
cyclosporine caps $0(Tier 1) PA MO
ENBREL $0(Tier 2) QL (8 per 28 days) PA
MO
ENBREL SURECLICK $0(Tier 2) QL (8 per 28 days) PA
MO
ENVARSUS XR $0(Tier 2) PA
gengraf caps 50mg $0(Tier 1) PA
gengraf caps 100mg, 25mg $0(Tier 1) PA MO
gengraf soln $0(Tier 1) PA MO
hecoria $0(Tier 1) PA
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK
$0(Tier 2) QL (6 per 28 days) PA
MO
HUMIRA PEN $0(Tier 2) QL (6 per 28 days) PA
MO
HUMIRA PEN-CROHNS DISEASESTARTER $0(Tier 2) QL (6 per 28 days) PA
MO
HUMIRA PEN-PSORIASIS STARTER $0(Tier 2) QL (6 per 28 days) PA
MO
HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML $0(Tier 2) QL (2 per 28 days) PA
MO
HUMIRA INJ 40MG/0.8ML $0(Tier 2) QL (6 per 28 days) PA
MO
KINERET $0(Tier 2) QL (20.1 per 30 days) PA
55 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
methotrexate sodium inj 1gm/40ml, 1gm, 250mg/10ml,
50mg/2ml
$0(Tier 1)
methotrexate tabs $0(Tier 1)
mycophenolate mofetil $0(Tier 1) PA
mycophenolic acid dr $0(Tier 1) PA
NULOJIX $0(Tier 2) PA MO
PROGRAF INJ $0(Tier 2) PA
RAPAMUNE SOLN $0(Tier 2) PA
REMICADE $0(Tier 2) PA
SANDIMMUNE SOLN $0(Tier 2) PA
sirolimus tabs $0(Tier 1) PA MO
tacrolimus caps 0.5mg, 1mg, 5mg $0(Tier 1) PA MO
TORISEL $0(Tier 2) B/D
ZORTRESS $0(Tier 2) B/D
Immunizing Agents, Passive
ATGAM $0(Tier 2) PA
BIVIGAM $0(Tier 2) B/D
FLEBOGAMMA DIF $0(Tier 2) B/D
GAMASTAN S/D $0(Tier 2) B/D
GAMMAGARD LIQUID INJ 2.5GM/25ML, 30GM/300ML $0(Tier 2) B/D
GAMMAKED $0(Tier 2) B/D
GAMMAPLEX INJ 10GM/200ML, 2.5GM/50ML,
5GM/100ML
$0(Tier 2) B/D
GAMUNEX-C $0(Tier 2) B/D
OCTAGAM INJ 10GM/100ML, 10GM/200ML, 1GM/20ML,
2.5GM/50ML, 20GM/200ML, 2GM/20ML, 5GM/100ML,
5GM/50ML
$0(Tier 2) B/D
PRIVIGEN INJ 10GM/100ML, 20GM/200ML, 5GM/50ML $0(Tier 2) B/D
THYMOGLOBULIN $0(Tier 2) B/D
Immunomodulators
ACTIMMUNE $0(Tier 2) PA
ARCALYST $0(Tier 2) PA
ILARIS $0(Tier 2) PA
leflunomide $0(Tier 1) QL (30 per 30 days) MO
RIDAURA $0(Tier 2) MO
SIMULECT $0(Tier 2) B/D
SYNAGIS INJ 50MG/0.5ML $0(Tier 2) PA
Vaccines
ACTHIB $0(Tier 2)
ADACEL $0(Tier 2)
BEXSERO $0(Tier 2)
BOOSTRIX $0(Tier 2)
56 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
CERVARIX $0(Tier 2)
COMVAX $0(Tier 2)
DAPTACEL $0(Tier 2)
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC
$0(Tier 2)
ENGERIX-B $0(Tier 2) B/D
GARDASIL $0(Tier 2)
GARDASIL 9 $0(Tier 2)
HAVRIX $0(Tier 2)
HIBERIX $0(Tier 2)
IMOVAX RABIES (H.D.C.V.) $0(Tier 2)
INFANRIX $0(Tier 2)
IPOL INACTIVATED IPV $0(Tier 2)
IXIARO $0(Tier 2)
KINRIX $0(Tier 2)
M-M-R II $0(Tier 2)
MENACTRA $0(Tier 2)
MENHIBRIX $0(Tier 2)
MENOMUNE-A/C/Y/W-135 $0(Tier 2)
MENVEO $0(Tier 2)
PEDVAX HIB $0(Tier 2)
PROQUAD $0(Tier 2)
QUADRACEL $0(Tier 2)
RABAVERT $0(Tier 2)
RECOMBIVAX HB $0(Tier 2) B/D
ROTARIX $0(Tier 2)
ROTATEQ $0(Tier 2)
TENIVAC $0(Tier 2)
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED $0(Tier 2)
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT $0(Tier 2)
TRUMENBA $0(Tier 2)
TWINRIX $0(Tier 2)
TYPHIM VI $0(Tier 2)
VAQTA $0(Tier 2)
VARIVAX $0(Tier 2)
VARIZIG $0(Tier 2)
YF-VAX $0(Tier 2)
ZOSTAVAX $0(Tier 2)
Inflammatory Bowel Disease Agents
(Drugs that Treat Inflammation of the Bowels)
Aminosalicylates
APRISO $0(Tier 2) MO
57 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
balsalazide disodium $0(Tier 1) MO
DELZICOL $0(Tier 2) MO
mesalamine enem, kit $0(Tier 1) MO
Glucocorticoids
budesonide cpep 3mg $0(Tier 1)
colocort $0(Tier 1)
hydrocortisone enem 100mg/60ml $0(Tier 1)
Sulfonamides
sulfasalazine tabs, tbec $0(Tier 1) MO
Metabolic Bone Disease Agents (Drugs that Treat Weak Bones)
Metabolic Bone Disease Agents
alendronate sodium tabs 10mg, 40mg, 5mg $0(Tier 1) QL (30 per 30 days) MO
alendronate sodium tabs 35mg $0(Tier 1) QL (4 per 28 days)
alendronate sodium tabs 70mg $0(Tier 1) QL (4 per 28 days) MO
calcitonin-salmon $0(Tier 1) QL (3.7 per 30 days) MO
calcitriol caps 0.25mcg, 0.5mcg $0(Tier 1) MO
calcitriol inj 1mcg/ml $0(Tier 1)
calcitriol oral soln 1mcg/ml $0(Tier 1) MO
doxercalciferol inj $0(Tier 1)
doxercalciferol caps $0(Tier 1) MO
etidronate disodium $0(Tier 1)
FORTEO $0(Tier 2) QL (2.4 per 28 days) PA
MO
ibandronate sodium tabs $0(Tier 1) QL (1 per 28 days) MO
MIACALCIN INJ $0(Tier 2)
pamidronate disodium inj 30mg, 90mg $0(Tier 1) B/D
pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml $0(Tier 1) B/D MO
paricalcitol caps $0(Tier 1)
PROLIA $0(Tier 2) QL (1 per 180 days) ST
risedronate sodium tabs 150mg $0(Tier 1) QL (1 per 28 days) MO
risedronate sodium tabs 30mg, 5mg $0(Tier 1) QL (30 per 30 days) MO
risedronate sodium tabs 35mg $0(Tier 1) QL (4 per 28 days) MO
XGEVA $0(Tier 2) PA
zoledronic acid $0(Tier 1) B/D
Miscellaneous Therapeutic Agents (Other Drugs)
Miscellaneous Therapeutic Agents
active 1st blood lancets 30g/easy twist cap $0(Tier 1) MC
aerovent plus holding chamber/collapsible $0(Tier 1) MC
assure prism multi test strips $0(Tier 1) MC
bd autoshield duo 30g x 3/16" $0(Tier 1) MC
bd eclipse syringe/1ml/30gx1/2" $0(Tier 1) QL (200 per 30 days)
bd insulin syringe safetyglide/1ml/29g x 1/2" $0(Tier 1) QL (200 per 30 days)
58 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
bd insulin syringe ultrafine/0.3ml/31g x 5/16" $0(Tier 1) QL (200 per 30 days)
bd insulin syringe ultrafine/0.5ml/30g x 1/2" $0(Tier 1) QL (200 per 30 days)
bd insulin syringe ultrafine/1ml/31g x 5/16" $0(Tier 1) QL (200 per 30 days)
bd pen needle/mini/ultrafine/31g x 3/16" $0(Tier 1) QL (200 per 30 days) MO
bd pen needle/nano/ultra fine/32g x 4mm $0(Tier 1) QL (200 per 30 days) MO
bd pen needle/ultrafine/29g x 12.7mm $0(Tier 1) QL (200 per 30 days)
bd safetyglide 27g x 5/8" $0(Tier 1) QL (200 per 30 days)
clever choice anti-staticvalved holding chamber/adult large $0(Tier 1) MC
clever choice anti-staticvalved holding chamber/medium $0(Tier 1) MC
clever choice anti-staticvalved holding chamber/small $0(Tier 1) MC
compact space chamber/anti-static $0(Tier 1) MC
compact space chamber/anti-static/large mask $0(Tier 1) MC
compact space chamber/anti-static/medium mask $0(Tier 1) MC
compact space chamber/anti-static/small mask $0(Tier 1) MC
cvs lancets ultra-thin 30g $0(Tier 1) MC
easy mini eject lancing device $0(Tier 1) MC
enfamil enfalyte $0(Tier 1) MC
FERRIPROX $0(Tier 2) PA
fifty50 unilet lancets 33g $0(Tier 1) MC
fomepizole $0(Tier 1)
fora d40/g31 blood glucose test strips $0(Tier 1) MC
fora lancets $0(Tier 1) MC
fora lancing device/clearcap $0(Tier 1) MC
fora tn'g/tn'g voice blood glucose test strips $0(Tier 1) MC
freestyle precision neo blood glucose test strips $0(Tier 1) MC
glucose meter test strips advanced $0(Tier 1) MC
gnp easy touch glucose test strips $0(Tier 1) MC
h-e-b incontrol lancets micro thin 33g $0(Tier 1) MC
inspirachamber/large $0(Tier 1) MC
INTRALIPID INJ 30GM/100ML $0(Tier 2) B/D
LACTATED RINGERS IRRIGATION $0(Tier 2)
levocarnitine inj, tabs $0(Tier 1)
levocarnitine oral soln $0(Tier 1) MO
mask vortex/child/frog $0(Tier 1) MC
mask vortex/toddler/lady bug $0(Tier 1) MC
multi-lancet device 2 $0(Tier 1) MC
NATPARA $0(Tier 2) PA
novofine 30gx8mm $0(Tier 1) QL (200 per 30 days) MO
novofine 31 $0(Tier 1) QL (200 per 30 days) MO
novofine 32gx6mm $0(Tier 1) QL (200 per 30 days) MO
novofine autocover 30gx8mm $0(Tier 1) QL (200 per 30 days) MO
novotwist 30gx8mm $0(Tier 1) QL (200 per 30 days) MO
59 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
novotwist 32gx5mm $0(Tier 1) QL (200 per 30 days)
one-way valved expiratorymouthpiece/disposable $0(Tier 1) MC
one-way valved inspiratory mouthpiece/disposable $0(Tier 1) MC
panda mask large $0(Tier 1) MC
panda mask medium $0(Tier 1) MC
panda mask small $0(Tier 1) MC
pantothenic acid $0(Tier 1) MC
pediatric medium mask $0(Tier 1) MC
pediatric mouthpiece/disposable $0(Tier 1) MC
pediatric panda mask $0(Tier 1) MC
pediatric small mask $0(Tier 1) MC
pharmacist choice no coding blood glucose test strips $0(Tier 1) MC
pharmacist choice ultra thin lancets 33g $0(Tier 1) MC
PHYSIOLYTE $0(Tier 2)
PHYSIOSOL IRRIGATION $0(Tier 2)
premium blood glucose test strips $0(Tier 1) MC
pro comfort lancets 30g $0(Tier 1) MC
prodigy safety lancets $0(Tier 1) MC
qc unilet lancets 33g/micro thin $0(Tier 1) MC
relion prime blood glucose test strips $0(Tier 1) MC
RINGERS IRRIGATION $0(Tier 2)
sidestream pediatric facemask $0(Tier 1) MC
sidestream pediatric facemask/tucker the turtle $0(Tier 1) MC
silicone mask for breatherite chamber/pediatric $0(Tier 1) MC
SODIUM CHLORIDE 0.9% $0(Tier 2)
sterile water irrigation $0(Tier 1)
suspendol-s $0(Tier 1) MC
thyrosafe $0(Tier 1) MC
thyroshield $0(Tier 1) MC
true metrix self monitoring blood glucose strips $0(Tier 1) MC
unilet lancets micro-thin33g $0(Tier 1) MC
zinc/vitamin c $0(Tier 1) MC
Ophthalmic Agents (Drugs that Relieve or Prevent Eye Problems)
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost $0(Tier 1) QL (5 per 30 days) MO
COMBIGAN $0(Tier 2) MO
latanoprost $0(Tier 1) QL (5 per 30 days) MO
LUMIGAN $0(Tier 2) QL (5 per 30 days) MO
TRAVATAN Z $0(Tier 2) QL (5 per 30 days) MO
ZIOPTAN $0(Tier 2) QL (30 per 30 days)
Ophthalmic Agents, Other
akwa tears $0(Tier 1) MC
60 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
artificial tears oint $0(Tier 1) MC
artificial tears soln 1.4% $0(Tier 1) MC
atropine sulfate ophthalmic soln 1% $0(Tier 1)
eye drops soln 0.05% $0(Tier 1) MC
FRESHKOTE $0(Tier 1) MC
ISOPTO TEARS $0(Tier 1) MC
LACRISERT $0(Tier 2)
liquitears $0(Tier 1) MC
lubricating plus eye drops $0(Tier 1) MC
lubrifresh p.m. $0(Tier 1) MC
MURO 128 SOLN $0(Tier 1) MC
mydral $0(Tier 1)
naphazoline hcl $0(Tier 1)
natural balance tears soln 0.4% $0(Tier 1) MC
natures tears soln 0.4% $0(Tier 1) MC
opti-clear $0(Tier 1) MC
proparacaine hcl $0(Tier 1)
puralube $0(Tier 1) MC
REFRESH CELLUVISC $0(Tier 1) MC
REFRESH LACRI-LUBE $0(Tier 1) MC
REFRESH PLUS $0(Tier 1) MC
RESTASIS $0(Tier 2) QL (64 per 30 days) MO
sodium chloride oint 5% $0(Tier 1) MC
sodium chloride ophthalmic soln 5% $0(Tier 1) MC
tropicamide $0(Tier 1)
Ophthalmic Anti-allergy Agents
ALOCRIL $0(Tier 2)
azelastine hcl ophthalmic soln 0.05% $0(Tier 1)
cromolyn sodium soln 4% $0(Tier 1)
epinastine hcl $0(Tier 1)
olopatadine hcl $0(Tier 1)
PATADAY $0(Tier 2)
PAZEO $0(Tier 2)
Ophthalmic Anti-inflammatories
bromfenac $0(Tier 1)
dexamethasone sodium phosphate ophthalmic soln 0.1% $0(Tier 1)
diclofenac sodium ophthalmic soln 0.1% $0(Tier 1) MO
DUREZOL $0(Tier 2)
fluorometholone $0(Tier 1)
flurbiprofen sodium $0(Tier 1) MO
ILEVRO $0(Tier 2)
ketorolac tromethamine $0(Tier 1)
61 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
LOTEMAX $0(Tier 2)
neomycin/polymyxin/dexamethasone $0(Tier 1)
PRED MILD $0(Tier 2)
PRED-G $0(Tier 2)
PRED-G S.O.P. $0(Tier 2)
prednisolone acetate $0(Tier 1)
prednisolone sodium phosphate ophthalmic soln 1% $0(Tier 1)
TOBRADEX OINT $0(Tier 2)
tobramycin/dexamethasone $0(Tier 1)
Ophthalmic Antiglaucoma Agents
acetazolamide er $0(Tier 1) MO
apraclonidine $0(Tier 1) MO
AZOPT $0(Tier 2)
betaxolol hcl soln 0.5% $0(Tier 1) MO
brimonidine tartrate soln 0.15% $0(Tier 1)
brimonidine tartrate soln 0.2% $0(Tier 1) MO
carteolol hcl $0(Tier 1) MO
dorzolamide hcl $0(Tier 1) MO
dorzolamide hcl/timolol maleate $0(Tier 1) MO
levobunolol hcl $0(Tier 1) MO
methazolamide tabs $0(Tier 1) MO
metipranolol $0(Tier 1) MO
PHOSPHOLINE IODIDE $0(Tier 2)
pilocarpine hcl soln 1%, 2%, 4% $0(Tier 1)
SIMBRINZA $0(Tier 2)
timolol maleate soln 0.25%, 0.5% $0(Tier 1) MO
Otic Agents (Drugs that Relieve or Prevent Ear Problems)
Otic Agents
acetasol hc $0(Tier 1)
acetic acid $0(Tier 1)
acetic acid/aluminum acetate $0(Tier 1)
COLY-MYCIN S $0(Tier 2)
CORTISPORIN-TC $0(Tier 2)
ear drops earwax removal aid $0(Tier 1) MC
earwax treatment drops $0(Tier 1) MC
fluocinolone acetonide oil 0.01% $0(Tier 1)
hydrocortisone/acetic acid $0(Tier 1)
neomycin/polymyxin/hc $0(Tier 1)
neomycin/polymyxin/hydrocortisone soln 1%; 3.5mg/ml;
10000unit/ml
$0(Tier 1)
neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml;
10000unit/ml
$0(Tier 1)
62 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
Respiratory Tract/Pulmonary Agents (Drugs that are used for Breathing Problems)
Anti-inflammatories, Inhaled Corticosteroids
budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml $0(Tier 1) QL (120 per 30 days) B/D
budesonide nasal susp 32mcg/act $0(Tier 1) QL (17.2 per 30 days)
DULERA $0(Tier 2) QL (18 per 30 days) MO
FLOVENT DISKUS AEPB 250MCG/BLIST, 50MCG/BLIST $0(Tier 2) QL (120 per 30 days) MO
FLOVENT DISKUS AEPB 100MCG/BLIST $0(Tier 2) QL (180 per 30 days) MO
FLOVENT HFA AERO 44MCG/ACT $0(Tier 2) QL (22 per 30 days) MO
FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT $0(Tier 2) QL (24 per 30 days) MO
flunisolide $0(Tier 1)
fluticasone propionate susp 50mcg/act $0(Tier 1) MC
fluticasone propionate susp 50mcg/act $0(Tier 1) QL (16 per 30 days)
QVAR $0(Tier 2) QL (18 per 30 days) MO
SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT $0(Tier 2) QL (12 per 30 days) MO
SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT $0(Tier 2) QL (14 per 30 days) MO
triamcinolone acetonide aero 55mcg/act $0(Tier 1) QL (16.5 per 30 days) MO
Antihistamines
aceta-gesic $0(Tier 1) MC
acetaminophen/diphenhydramine $0(Tier 1) MC
ALA-HIST IR $0(Tier 1) MC
ALA-HIST PE $0(Tier 1) MC
all day allergy childrens chew $0(Tier 1) MC
all day allergy childrens soln 5mg/5ml $0(Tier 1) MC
all day allergy-d $0(Tier 1) MC
all day allergy tabs $0(Tier 1) MC
aller-chlor $0(Tier 1) MC
allergy relief child $0(Tier 1) MC
allergy relief d-24 $0(Tier 1) MC
allergy relief tabs 10mg $0(Tier 1) MC
allergy tbdp $0(Tier 1) MC
allergy tabs 10mg, 4mg $0(Tier 1) MC
azelastine hcl nasal soln 0.1%, 0.15% $0(Tier 1) QL (60 per 30 days) MO
banophen caps 50mg $0(Tier 1) MC
banophen liqd $0(Tier 1) MC
BROTAPP $0(Tier 1) MC
cetirizine hcl allergy childrens $0(Tier 1) MC
cetirizine hcl childrens allergy syrp 1mg/ml $0(Tier 1) MC
cetirizine hcl/pseudoephedrine hcl er $0(Tier 1) MC
cetirizine hcl chew, tabs $0(Tier 1) MC
childrens allergy $0(Tier 1) MC
childrens loratadine $0(Tier 1) MC
complete allergy medicine caps $0(Tier 1) MC
63 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
dallergy tabs $0(Tier 1) MC
dallergy liqd 1mg/ml; 2.5mg/ml $0(Tier 1) MC
desloratadine $0(Tier 1) QL (30 per 30 days) MO
desloratadine odt $0(Tier 1) QL (30 per 30 days)
dimaphen childrens $0(Tier 1) MC
diphenhist liqd $0(Tier 1) MC
diphenhydramine hcl inj $0(Tier 1)
diphenhydramine hcl caps $0(Tier 1) MC
ed a-hist $0(Tier 1) MC
ed a-hist pse $0(Tier 1) MC
ed chlorped $0(Tier 1) MC
ed chlorped d $0(Tier 1) MC
ed chlorped jr $0(Tier 1) MC
ed-chlortan $0(Tier 1) MC
fexofenadine hcl $0(Tier 1) MC
fexofenadine hcl childrens allergy $0(Tier 1) MC
gnp all day allergy $0(Tier 1) MC
gnp allergy tabs 4mg $0(Tier 1) MC
gnp dayhist allergy $0(Tier 1) MC
gnp loratadine $0(Tier 1) MC
histex $0(Tier 1) MC
histex pd $0(Tier 1) MC
J-TAN D PD $0(Tier 1) MC
J-TAN PD $0(Tier 1) MC
levocetirizine dihydrochloride tabs $0(Tier 1) QL (30 per 30 days) MO
levocetirizine dihydrochloride soln $0(Tier 1) QL (300 per 30 days) MO
LODRANE D $0(Tier 1) MC
lohist-d $0(Tier 1) MC
loratadine childrens $0(Tier 1) MC
loratadine hives relief $0(Tier 1) MC
loratadine-d 12hr $0(Tier 1) MC
loratadine-d 24hr $0(Tier 1) MC
loratadine tabs $0(Tier 1) MC
NASOPEN PE $0(Tier 1) MC
night time sleep aid $0(Tier 1) MC
nohist-lq $0(Tier 1) MC
POLY-HIST PD $0(Tier 1) MC
promethazine/codeine syrp 10mg/5ml; 6.25mg/5ml $0(Tier 1) MC
q-dryl $0(Tier 1) MC
qc loratadine allergy relief $0(Tier 1) MC
qc loratadine-d $0(Tier 1) MC
quenalin $0(Tier 1) MC
64 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
RESCON TABS $0(Tier 1) MC
restfully sleep $0(Tier 1) MC
ru-hist d $0(Tier 1) MC
rymed $0(Tier 1) MC
rynex pe $0(Tier 1) MC
rynex pse $0(Tier 1) MC
siladryl allergy $0(Tier 1) MC
silphen cough $0(Tier 1) MC
sm allergy 4 hour $0(Tier 1) MC
sm allergy relief liqd $0(Tier 1) MC
sm allergy relief tabs 1.34mg $0(Tier 1) MC
sm lorata-dine d $0(Tier 1) MC
sm loratadine syrp $0(Tier 1) MC
sm sleep aid $0(Tier 1) MC
sudogest sinus & allergy $0(Tier 1) MC
VANAHIST PD $0(Tier 1) MC
virdec $0(Tier 1) MC
Antileukotrienes
montelukast sodium $0(Tier 1) QL (30 per 30 days) MO
zafirlukast $0(Tier 1) MO
Bronchodilators, Anticholinergic
ATROVENT HFA $0(Tier 2) QL (26 per 30 days) MO
COMBIVENT RESPIMAT $0(Tier 2) QL (8 per 30 days) MO
ipratropium bromide/albuterol sulfate $0(Tier 1) QL (540 per 30 days) B/D
MO
ipratropium bromide inhalation soln $0(Tier 1) QL (300 per 30 days) B/D
MO
ipratropium bromide nasal soln 0.06% $0(Tier 1) QL (30 per 30 days) MO
ipratropium bromide nasal soln 0.03% $0(Tier 1) QL (60 per 30 days) MO
SPIRIVA HANDIHALER $0(Tier 2) QL (30 per 30 days) MO
SPIRIVA RESPIMAT $0(Tier 2) QL (4 per 30 days)
Bronchodilators, Sympathomimetic
albuterol sulfate er $0(Tier 1) MO
albuterol sulfate syrp, tabs $0(Tier 1) MO
albuterol sulfate nebu 0.5% $0(Tier 1) QL (360 per 30 days) B/D
MO
albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml $0(Tier 1) QL (375 per 30 days) B/D
MO
albuterol tabs $0(Tier 1)
epinephrine hcl $0(Tier 1)
EPIPEN 2-PAK $0(Tier 2) QL (2 per 30 days)
EPIPEN-JR 2-PAK $0(Tier 2) QL (2 per 30 days)
65 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
FORADIL AEROLIZER $0(Tier 2) QL (60 per 30 days) MO
metaproterenol sulfate syrp, tabs $0(Tier 1) MO
PERFOROMIST $0(Tier 2) QL (120 per 30 days) B/D
PROAIR HFA $0(Tier 2) QL (17 per 30 days) MO
PROAIR RESPICLICK $0(Tier 2) QL (1.3 per 30 days)
S2 $0(Tier 1) MC
SEREVENT DISKUS $0(Tier 2) QL (60 per 30 days)
STRIVERDI RESPIMAT $0(Tier 2) QL (4 per 30 days)
terbutaline sulfate inj $0(Tier 1)
terbutaline sulfate tabs $0(Tier 1) MO
Cystic Fibrosis Agents
CAYSTON $0(Tier 2) PA
KALYDECO $0(Tier 2) QL (60 per 30 days) PA
PULMOZYME $0(Tier 2) B/D
TOBI PODHALER $0(Tier 2) QL (1568 per 365 days)
tobramycin $0(Tier 1) B/D
Mast Cell Stabilizers
cromolyn sodium aers 5.2mg/act $0(Tier 1) MC
cromolyn sodium nebu 20mg/2ml $0(Tier 1) B/D MO
Phosphodiesterase Inhibitors, Airways Disease
aminophylline $0(Tier 1)
DALIRESP $0(Tier 2) QL (30 per 30 days) PA
MO
THEO-24 $0(Tier 2) MO
theochron $0(Tier 1) MO
theophylline cr tb12 100mg, 200mg $0(Tier 1) MO
theophylline er tb24 $0(Tier 1) MO
theophylline er tb12 100mg, 200mg $0(Tier 1)
theophylline er tb12 300mg, 450mg $0(Tier 1) MO
Pulmonary Antihypertensives
ADEMPAS $0(Tier 2) QL (90 per 30 days) PA
LETAIRIS $0(Tier 2) QL (30 per 30 days) PA
OPSUMIT $0(Tier 2) QL (30 per 30 days) PA
REMODULIN $0(Tier 2) B/D
sildenafil tabs $0(Tier 1) QL (90 per 30 days) PA
TRACLEER $0(Tier 2) QL (60 per 30 days) PA
Respiratory Tract Agents, Other
12 hour decongestant $0(Tier 1) MC
acetylcysteine soln $0(Tier 1) B/D
ALAHIST DM LIQD 4MG/5ML; 15MG/5ML; 7.5MG/5ML $0(Tier 1) MC
all-nite cold & flu nighttime relief $0(Tier 1) MC
66 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
all-nite multi-symptom cold/flu relief liqd 325mg/15ml;
15mg/15ml; 6.25mg/15ml
$0(Tier 1) MC
ap-hist dm $0(Tier 1) MC
aprodine $0(Tier 1) MC
ARALAST NP INJ 500MG, 800MG $0(Tier 2) B/D
benzonatate $0(Tier 1) MC
bromfed dm $0(Tier 1) MC
bromphen/pseudoephedrine hcl/dextromethorphan hbr $0(Tier 1) MC
BROTAPP DM $0(Tier 1) MC
cheratussin ac syrp $0(Tier 1) MC
cheratussin dac $0(Tier 1) MC
chest congestion relief $0(Tier 1) MC
chest congestion relief pe $0(Tier 1) MC
childrens silfedrine $0(Tier 1) MC
CHLO TUSS EX $0(Tier 1) MC
chlo tuss liqd 12.5mg/5ml; 1mg/5ml; 30mg/5ml $0(Tier 1) MC
codeine/guaifenesin soln $0(Tier 1) MC
cold/cough dm childrens $0(Tier 1) MC
cough dm $0(Tier 1) MC
cough syrup syrp 100mg/5ml $0(Tier 1) MC
day time multi-symptom cold/flu relief caps $0(Tier 1) MC
DECONEX DMX TABS 15MG; 380MG; 10MG $0(Tier 1) MC
DECONEX IR TABS 380MG; 10MG $0(Tier 1) MC
deep sea nasal spray $0(Tier 1) MC
delsym cough + chest congestion dm $0(Tier 1) MC
delsym cough + chest congestion dm childrens $0(Tier 1) MC
delsym cough + cold daytime $0(Tier 1) MC
delsym cough + cold nighttime $0(Tier 1) MC
delsym cough + cold nighttime childrens $0(Tier 1) MC
DELSYM SUER $0(Tier 1) MC
dextromethorphan polistirex $0(Tier 1) MC
dimaphen dm cold & cough $0(Tier 1) MC
dimaphen dm cold/cough childrens $0(Tier 1) MC
DURAFLU TABS 500MG; 20MG; 200MG; 60MG $0(Tier 1) MC
ed a-hist dm $0(Tier 1) MC
ed bron gp $0(Tier 1) MC
endacof-dm $0(Tier 1) MC
ESBRIET $0(Tier 2) PA
extra action cough $0(Tier 1) MC
FLOWTUSS $0(Tier 1) MC
gnp tussin $0(Tier 1) MC
gnp tussin dm $0(Tier 1) MC
67 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
guaiatussin ac $0(Tier 1) MC
guaifenesin ac $0(Tier 1) MC
guaifenesin and pseudoephedrine hydrochloride $0(Tier 1) MC
guaifenesin er $0(Tier 1) MC
guaifenesin/codeine $0(Tier 1) MC
histex-dm $0(Tier 1) MC
histex-pe $0(Tier 1) MC
HYCOFENIX $0(Tier 1) MC
hydrocodone bitartrate/chlorpheniramine maleate/pse $0(Tier 1) MC
hydrocodone bitartrate/homatropine methylbromide $0(Tier 1) MC
hydrocodone polistirex/chlorpheniramine polistirex $0(Tier 1) MC
hydrocodone/homatropine $0(Tier 1) MC
hydromet $0(Tier 1) MC
iophen c-nr $0(Tier 1) MC
iophen dm-nr $0(Tier 1) MC
iophen-nr $0(Tier 1) MC
iosat $0(Tier 1) MC
J-MAX SYRP $0(Tier 1) MC
kidkare cough/cold $0(Tier 1) MC
lohist-dm $0(Tier 1) MC
lortuss dm $0(Tier 1) MC
lortuss ex $0(Tier 1) MC
lortuss lq $0(Tier 1) MC
M-END DMX $0(Tier 1) MC
M-END MAX D $0(Tier 1) MC
mapap cold formula multi-symptom $0(Tier 1) MC
mapap sinus maximum strength congestion and pain $0(Tier 1) MC
mucaphed $0(Tier 1) MC
mucinex chest congestion childrens $0(Tier 1) MC
mucinex childrens cold cough & sore throat $0(Tier 1) MC
mucinex childrens multi-symptom cold $0(Tier 1) MC
MUCINEX CHILDRENS MULTI-SYMPTOM COLD &
FEVER
$0(Tier 1) MC
mucinex congestion & cough childrens $0(Tier 1) MC
mucinex cough childrens $0(Tier 1) MC
MUCINEX COUGH FOR KIDS PACK $0(Tier 1) MC
MUCINEX D $0(Tier 1) MC
MUCINEX D MAXIMUM STRENGTH TB12 1200MG;
120MG
$0(Tier 1) MC
mucinex d maximum strength tb12 1200mg; 120mg $0(Tier 1) MC
MUCINEX DM $0(Tier 1) MC
68 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
MUCINEX DM MAXIMUM STRENGTH TB12 60MG;
1200MG
$0(Tier 1) MC
mucinex dm maximum strength tb12 60mg; 1200mg $0(Tier 1) MC
mucinex fast-max cold & sinus tabs $0(Tier 1) MC
MUCINEX FAST-MAX COLD FLU& SORE THROAT
LIQD
$0(Tier 1) MC
mucinex fast-max cold flu& sore throat tabs $0(Tier 1) MC
mucinex fast-max day time/night time misc 650mg/20ml;
20mg/20ml; 25mg/20ml; 400mg/20ml; 10mg/20ml
$0(Tier 1) MC
mucinex fast-max day/night maximum strength $0(Tier 1) MC
mucinex fast-max dm max $0(Tier 1) MC
mucinex fast-max night time cold & flu liqd, tabs $0(Tier 1) MC
mucinex fast-max severe cold $0(Tier 1) MC
mucinex fast-max severe congestion & cough $0(Tier 1) MC
MUCINEX FOR KIDS PACK 100MG $0(Tier 1) MC
mucinex maximum strength $0(Tier 1) MC
mucinex multi-symptom cold day/night pack $0(Tier 1) MC
mucinex multi-symptom cold night time childrens $0(Tier 1) MC
mucinex sinus-max day/night misc $0(Tier 1) MC
mucinex sinus-max full force $0(Tier 1) MC
mucinex sinus-max moisture smart $0(Tier 1) MC
mucinex sinus-max pressure & pain tabs $0(Tier 1) MC
mucinex sinus-max severe congestion relief tabs $0(Tier 1) MC
mucinex stuffy nose & cold childrens $0(Tier 1) MC
MUCINEX TB12 600MG $0(Tier 1) MC
mucinex tb12 600mg $0(Tier 1) MC
mucus relief $0(Tier 1) MC
mucus-er $0(Tier 1) MC
mucusrelief sinus $0(Tier 1) MC
nasal decongestant pe $0(Tier 1) MC
nasal decongestant spray $0(Tier 1) MC
nasal decongestant soln, syrp $0(Tier 1) MC
night time multi-symptom cold/flu relief $0(Tier 1) MC
ninjacof $0(Tier 1) MC
ninjacof-a $0(Tier 1) MC
ninjacof-xg $0(Tier 1) MC
nohist-dm $0(Tier 1) MC
nrs nasal relief $0(Tier 1) MC
organ-i nr $0(Tier 1) MC
pain relief sinus pe daytime $0(Tier 1) MC
pediatric cough/cold $0(Tier 1) MC
phenylephrine hcl/pyrilamine maleate $0(Tier 1) MC
69 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
phenylhistine dh $0(Tier 1) MC
POLY-HIST DM $0(Tier 1) MC
poly-vent dm $0(Tier 1) MC
poly-vent ir $0(Tier 1) MC
PROLASTIN-C $0(Tier 2) B/D
promethazine vc/codeine $0(Tier 1) MC
promethazine-dm $0(Tier 1) MC
promethazine/codeine syrp 10mg/5ml; 6.25mg/5ml $0(Tier 1) MC
promethazine/dextromethorphan $0(Tier 1) MC
pseudoephedrine hcl tabs 30mg $0(Tier 1) MC
q-tussin $0(Tier 1) MC
q-tussin dm $0(Tier 1) MC
qc cough/sore throat nighttime $0(Tier 1) MC
RESCON DM $0(Tier 1) MC
RESCON-GG $0(Tier 1) MC
RESPAIRE-30 $0(Tier 1) MC
REZIRA $0(Tier 1) MC
robafen $0(Tier 1) MC
robafen cf cough & cold $0(Tier 1) MC
robafen cf multi-symptom cold $0(Tier 1) MC
robafen cough $0(Tier 1) MC
robafen dm $0(Tier 1) MC
robafen dm cough clear $0(Tier 1) MC
rynex dm $0(Tier 1) MC
siltussin dm das $0(Tier 1) MC
siltussin sa $0(Tier 1) MC
siltussin-dm $0(Tier 1) MC
sm nasal decongestant maximum strength $0(Tier 1) MC
sm nasal spray 12 hour $0(Tier 1) MC
sm tussin $0(Tier 1) MC
sm tussin dm $0(Tier 1) MC
sm tussin dm cough/chest congestion $0(Tier 1) MC
stahist ad $0(Tier 1) MC
STIOLTO RESPIMAT $0(Tier 2)
sudogest $0(Tier 1) MC
sudogest 12 hour $0(Tier 1) MC
sudogest pe $0(Tier 1) MC
tussin dm $0(Tier 1) MC
tussin dm clear $0(Tier 1) MC
TUSSIONEX PENNKINETIC EXTENDED RELEASE $0(Tier 1) MC
TYZINE PEDIATRIC NASAL DROPS $0(Tier 2)
VANACOF $0(Tier 1) MC
70 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
VANACOF DM $0(Tier 1) MC
VANACOF-8 $0(Tier 1) MC
VIRAZOLE $0(Tier 2) B/D
virdec dm $0(Tier 1) MC
virtussin a/c $0(Tier 1) MC
XOLAIR $0(Tier 2) PA
ZEMAIRA $0(Tier 2) B/D
zinc mouth/throat lozg 10mg $0(Tier 1) MC
ZONATUSS $0(Tier 1) MC
ZUTRIPRO $0(Tier 1) MC
Skeletal Muscle Relaxants (Drugs that Relax Muscle Cramps or Stiff Muscles)
Skeletal Muscle Relaxants
cyclobenzaprine hcl tabs 10mg, 5mg $0(Tier 1) PA
orphenadrine citrate er $0(Tier 1) PA
Sleep Disorder Agents (Drugs that help with Sleep Problems)
GABA Receptor Modulators
temazepam $0(Tier 1) QL (90 per 365 days) MO
zaleplon $0(Tier 1) QL (90 per 365 days)
zolpidem tartrate tabs $0(Tier 1) PA
Sleep Disorders, Other
armodafinil $0(Tier 1) QL (30 per 30 days) PA
modafinil tabs 100mg $0(Tier 1) QL (30 per 30 days) PA
MO
modafinil tabs 200mg $0(Tier 1) QL (60 per 30 days) PA
MO
NUVIGIL $0(Tier 2) QL (30 per 30 days) PA
ROZEREM $0(Tier 2) QL (30 per 30 days)
SILENOR $0(Tier 2) QL (30 per 30 days) MO
XYREM $0(Tier 2) QL (540 per 30 days) PA
Therapeutic Nutrients/Minerals/Electrolytes (Drugs used to Replace Nutrients, Minerals, and Electrolytes)
Electrolyte/Mineral Modifiers
CHEMET $0(Tier 2)
CUPRIMINE $0(Tier 2)
DEPEN TITRATABS $0(Tier 2)
EXJADE $0(Tier 2) MO
JADENU $0(Tier 2) MO
kionex $0(Tier 1)
SAMSCA TABS 30MG $0(Tier 2) QL (60 per 30 days) PA
SAMSCA TABS 15MG $0(Tier 2) QL (90 per 30 days) PA
sodium bicarbonate partial fill $0(Tier 1)
sodium bicarbonate inj 4.2%, 7.5%, 8.4% $0(Tier 1)
SODIUM LACTATE INJ 5MEQ/ML $0(Tier 2) B/D
71 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
sodium polystyrene sulfonate powd, oral susp $0(Tier 1)
sodium polystyrene sulfonate rectal susp 30gm/120ml $0(Tier 1)
sps $0(Tier 1)
SYPRINE $0(Tier 2)
Electrolyte/Mineral Replacement
AMINOSYN 7%/ELECTROLYTES $0(Tier 2) B/D
AMINOSYN 8.5%/ELECTROLYTES $0(Tier 2) B/D
AMINOSYN II $0(Tier 2) B/D
AMINOSYN II 8.5%/ELECTROLYTES $0(Tier 2) B/D
AMINOSYN M $0(Tier 2) B/D
AMINOSYN-HBC $0(Tier 2) B/D
AMINOSYN-PF $0(Tier 2) B/D
AMINOSYN-PF 7% $0(Tier 2) B/D
AMINOSYN-RF $0(Tier 2) B/D
AMINOSYN INJ 90MEQ/L; 1100MG/100ML;
850MG/100ML; 35MEQ/L; 1100MG/100ML;
260MG/100ML; 620MG/100ML; 810MG/100ML;
624MG/100ML; 340MG/100ML; 380MG/100ML;
5.4MEQ/L; 750MG/100ML; 370MG/100ML;
460MG/100ML; 150MG/100ML; 44MG/100ML;
680MG/100ML
$0(Tier 2) B/D
baby darlings pediatric electrolyte $0(Tier 1) MC
cal-mag-zinc-d $0(Tier 1) MC
calcet petites $0(Tier 1) MC
calci-chew $0(Tier 1) MC
calcitrate $0(Tier 1) MC
calcium & magnesium $0(Tier 1) MC
calcium + d3 $0(Tier 1) MC
calcium 500 +d3 $0(Tier 1) MC
calcium 500/d chew $0(Tier 1) MC
calcium 500/vitamin d3 $0(Tier 1) MC
calcium 600 $0(Tier 1) MC
calcium 600 + d tabs 600mg; 400unit $0(Tier 1) MC
calcium 600 with vitamin d $0(Tier 1) MC
calcium 600+d $0(Tier 1) MC
calcium 600+d3 tabs 600mg; 400unit, 600mg; 800unit $0(Tier 1) MC
calcium 600-d $0(Tier 1) MC
calcium 600/vitamin d $0(Tier 1) MC
calcium 600/vitamin d3 $0(Tier 1) MC
calcium carbonate/d3 $0(Tier 1) MC
calcium carbonate/vitamin d $0(Tier 1) MC
calcium carbonate chew 500mg $0(Tier 1) MC
72 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
calcium carbonate susp, tabs $0(Tier 1) MC
calcium citrate + d $0(Tier 1) MC
calcium citrate + d3 maximum $0(Tier 1) MC
calcium citrate malate/vitamin d $0(Tier 1) MC
calcium citrate maximum/vitamin d $0(Tier 1) MC
calcium citrate w/d $0(Tier 1) MC
calcium citrate+d $0(Tier 1) MC
calcium citrate/vitamin d3 tabs $0(Tier 1) MC
calcium citrate/vitamin d tabs 315mg; 200unit, 315mg;
250unit
$0(Tier 1) MC
calcium citrate tabs 200mg $0(Tier 1) MC
calcium gluconate tabs 500mg $0(Tier 1) MC
calcium high potency $0(Tier 1) MC
calcium high potency + vitamin d $0(Tier 1) MC
calcium oyster shell $0(Tier 1) MC
calcium+d3 $0(Tier 1) MC
calcium/d tabs $0(Tier 1) MC
calcium/magnesium/zinc tabs 1000mg; 1mg; 400mg; 15mg,
333.333mg; 133.333mg; 5mg, 333.33mg; 0.33mg; 133.33mg;
5mg, 333mg; 133mg; 5mg
$0(Tier 1) MC
calcium/vitamin d caps 600mg; 400unit $0(Tier 1) MC
calcium/vitamin d tabs 500mg; 200unit, 500mg; 400unit,
600mg; 200unit, 600mg; 400unit
$0(Tier 1) MC
calcium tabs 500mg, 600mg $0(Tier 1) MC
caltrate 600+d plus minerals tabs $0(Tier 1) MC
caltrate 600+d3 soft chews $0(Tier 1) MC
caltrate 600+d tabs 600mg; 800unit $0(Tier 1) MC
calvite p&d $0(Tier 1) MC
CARBAGLU $0(Tier 2)
centamin $0(Tier 1) MC
centratex $0(Tier 1) MC
citracal + d3 maximum $0(Tier 1) MC
citracal maximum $0(Tier 1) MC
CLINIMIX 2.75%/DEXTROSE 5% $0(Tier 2) B/D
CLINIMIX 4.25%/DEXTROSE 10% $0(Tier 2) B/D
CLINIMIX 4.25%/DEXTROSE 20% $0(Tier 2) B/D
CLINIMIX 4.25%/DEXTROSE 25% $0(Tier 2) B/D
CLINIMIX 4.25%/DEXTROSE 5% $0(Tier 2) B/D
CLINIMIX 5%/DEXTROSE 15% $0(Tier 2) B/D
CLINIMIX 5%/DEXTROSE 20% $0(Tier 2) B/D
CLINIMIX 5%/DEXTROSE 25% $0(Tier 2) B/D
CLINIMIX E 2.75%/DEXTROSE 10% $0(Tier 2) B/D
73 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
CLINIMIX E 4.25%/DEXTROSE 10% $0(Tier 2) B/D
CLINIMIX E 4.25%/DEXTROSE 25% $0(Tier 2) B/D
CLINIMIX E 5%/DEXTROSE 25% $0(Tier 2) B/D
CLINISOL SF 15% $0(Tier 2) B/D
coral calcium caps 100unit; 185mg; 50mg $0(Tier 1) MC
cvs calcium 600 & vitamind3 $0(Tier 1) MC
cvs calcium 600 + d/minerals $0(Tier 1) MC
cvs calcium 600+d $0(Tier 1) MC
cvs calcium carbonate $0(Tier 1) MC
cvs calcium chewables 600plus $0(Tier 1) MC
cvs calcium citrate + d $0(Tier 1) MC
cvs calcium citrate +d $0(Tier 1) MC
cvs calcium citrate+d/magnesium $0(Tier 1) MC
cvs electrolyte solution $0(Tier 1) MC
cvs iron $0(Tier 1) MC
cvs magnesium $0(Tier 1) MC
cvs oyster shell calcium w/ vit d $0(Tier 1) MC
cvs pediatric electrolyte $0(Tier 1) MC
cvs pediatric electrolyte freezer pops $0(Tier 1) MC
cvs selenium $0(Tier 1) MC
cvs slow release iron $0(Tier 1) MC
cvs zinc $0(Tier 1) MC
DEXTROSE 10%/NACL 0.45% $0(Tier 2) B/D
dextrose 5% /electrolyte #48 viaflex $0(Tier 1) B/D
DEXTROSE 10% $0(Tier 2) B/D
DEXTROSE 10%/NACL 0.2% $0(Tier 2) B/D
DEXTROSE 2.5%/NACL 0.45% $0(Tier 2) B/D
DEXTROSE 20% $0(Tier 2) B/D
DEXTROSE 25% $0(Tier 2) B/D
DEXTROSE 30% $0(Tier 2) B/D
DEXTROSE 40% $0(Tier 2) B/D
DEXTROSE 5% $0(Tier 2) B/D
DEXTROSE 5%/LACTATED RINGERS $0(Tier 2)
DEXTROSE 5%/NACL 0.2% $0(Tier 2) B/D
DEXTROSE 5%/NACL 0.225% $0(Tier 2) B/D
DEXTROSE 5%/NACL 0.3% $0(Tier 2) B/D
DEXTROSE 5%/NACL 0.33% $0(Tier 2) B/D
DEXTROSE 5%/NACL 0.45% $0(Tier 2) B/D
DEXTROSE 5%/NACL 0.9% $0(Tier 2) B/D
DEXTROSE 5%/POTASSIUM CHLORIDE 0.15% $0(Tier 2) B/D
DEXTROSE 50% $0(Tier 2) B/D
DEXTROSE 70% $0(Tier 2) B/D
74 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
duofer $0(Tier 1) MC
enlyte $0(Tier 1) MC
eql pediatric electrolyte $0(Tier 1) MC
ezfe 200 $0(Tier 1) MC
fe c $0(Tier 1) MC
fe c tab $0(Tier 1) MC
feosol bifera $0(Tier 1) MC
feosol tabs 200mg $0(Tier 1) MC
fer-in-sol $0(Tier 1) MC
fer-iron $0(Tier 1) MC
ferate $0(Tier 1) MC
fergon tabs 240mg $0(Tier 1) MC
feriva 21/7 $0(Tier 1) MC
ferivafa $0(Tier 1) MC
ferosul $0(Tier 1) MC
ferralet 90 $0(Tier 1) MC
ferraplus 90 $0(Tier 1) MC
ferretts $0(Tier 1) MC
ferretts ips $0(Tier 1) MC
ferrex 150 $0(Tier 1) MC
ferrex 150 forte $0(Tier 1) MC
ferric x-150 $0(Tier 1) MC
ferrimin 150 $0(Tier 1) MC
ferrocite $0(Tier 1) MC
ferrous drops $0(Tier 1) MC
ferrous fumarate 324 $0(Tier 1) MC
ferrous gluconate tabs 240mg, 324mg, 325mg $0(Tier 1) MC
ferrous sulfate elix, liqd, soln, syrp, tbcr, tbec $0(Tier 1) MC
ferrous sulfate tabs 325mg $0(Tier 1) MC
ferrousul $0(Tier 1) MC
fluoride chew 0.25mg, 1.1mg, 2.2mg $0(Tier 1)
fluoritab chew 0.5mg, 1mg $0(Tier 1)
focalgin dss $0(Tier 1) MC
FREAMINE HBC 6.9% $0(Tier 2) B/D
FREAMINE III INJ 89MEQ/L; 710MG/100ML;
950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML;
280MG/100ML; 690MG/100ML; 910MG/100ML;
730MG/100ML; 530MG/100ML; 560MG/100ML;
10MMOLE/L; 120MG/100ML; 1120MG/100ML;
590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML;
660MG/100ML
$0(Tier 2) B/D
fusion $0(Tier 1) MC
75 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
fusion plus $0(Tier 1) MC
gnp calcium $0(Tier 1) MC
gnp calcium 1200 $0(Tier 1) MC
gnp calcium 500 +d3 $0(Tier 1) MC
gnp calcium 500/d $0(Tier 1) MC
gnp calcium 600/d $0(Tier 1) MC
gnp calcium citrate +d3 $0(Tier 1) MC
gnp calcium citrate+d maximum $0(Tier 1) MC
gnp calcium/magnesium/zinc $0(Tier 1) MC
gnp calcuim/vitamin d/minerals $0(Tier 1) MC
gnp iron tbcr $0(Tier 1) MC
gnp iron tabs 200mg $0(Tier 1) MC
gnp magnesium tabs 250mg; 0; 0 $0(Tier 1) MC
gnp niacin tr $0(Tier 1) MC
gnp pediatric electrolyte $0(Tier 1) MC
gnp therapeutic-m $0(Tier 1) MC
gnp vitamin b-12 $0(Tier 1) MC
gnp vitamin b-12 tr $0(Tier 1) MC
gnp vitamin b-6 $0(Tier 1) MC
gnp vitamin c drops $0(Tier 1) MC
gnp vitamin c chew 500mg, 500mg; 0 $0(Tier 1) MC
gnp vitamin c tabs 1000mg, 250mg $0(Tier 1) MC
gnp vitamin e $0(Tier 1) MC
gnp zinc $0(Tier 1) MC
h-e-b oral electrolyte solution $0(Tier 1) MC
hemocyte $0(Tier 1) MC
hemocyte plus $0(Tier 1) MC
hemocyte-f tabs $0(Tier 1) MC
HEPATAMINE $0(Tier 2) B/D
hm pediatric electrolyte $0(Tier 1) MC
i.l.x. b-12 $0(Tier 1) MC
icar pediatric $0(Tier 1) MC
icar-c $0(Tier 1) MC
iferex 150 $0(Tier 1) MC
infed $0(Tier 1) MC
iron tabs 256mg, 27mg, 325mg $0(Tier 1) MC
irospan 24/6 $0(Tier 1) MC
k-sol $0(Tier 1)
KABIVEN $0(Tier 2) B/D
KCL 0.075%/D5W/NACL 0.45% $0(Tier 2) B/D
kcl 0.15%/d5w/ nacl 0.3% $0(Tier 1) B/D
KCL 0.15%/D5W/LR $0(Tier 2) B/D
76 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
KCL 0.15%/D5W/NACL 0.2% $0(Tier 2) B/D
kcl 0.15%/d5w/nacl 0.225% $0(Tier 1) B/D
kcl 0.15%/d5w/nacl 0.45% $0(Tier 1) B/D
KCL 0.15%/D5W/NACL 0.9% $0(Tier 2) B/D
KCL 0.3%/D5W/LR IV LAC RING $0(Tier 2) B/D
KCL 0.3%/D5W/NACL 0.45% $0(Tier 2) B/D
kcl 0.3%/d5w/nacl 0.9% $0(Tier 1) B/D
klor-con $0(Tier 1) MO
klor-con 10 $0(Tier 1)
klor-con 8 $0(Tier 1)
klor-con m10 $0(Tier 1) MO
klor-con m20 $0(Tier 1)
klor-con sprinkle $0(Tier 1)
kp ferrous gluconate $0(Tier 1) MC
kp ferrous sulfate $0(Tier 1) MC
LACTATED RINGERS VIAFLEX $0(Tier 2)
LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L;
28MEQ/L; 4MEQ/L; 130MEQ/L
$0(Tier 2)
liquid calcium/vitamin d $0(Tier 1) MC
ludent $0(Tier 1)
mag-tab sr $0(Tier 1) MC
magnesium 27 $0(Tier 1) MC
magnesium elemental $0(Tier 1) MC
magnesium sulfate in d5w $0(Tier 1) B/D
magnesium sulfate inj $0(Tier 1) B/D
magnesium tabs 250mg, 500mg $0(Tier 1) MC
monocal $0(Tier 1) MC
MOZOBIL $0(Tier 2) QL (9.6 per 30 days)
myferon 150 $0(Tier 1) MC
natalvirt flt $0(Tier 1) MC
NEPHRAMINE $0(Tier 2) B/D
nephron fa $0(Tier 1) MC
NORMOSOL -R $0(Tier 2) B/D
NORMOSOL-M IN D5W $0(Tier 2) B/D
NORMOSOL-R $0(Tier 2) B/D
NORMOSOL-R IN D5W $0(Tier 2) B/D
NOVAFERRUM 125 $0(Tier 1) MC
NOVAFERRUM 50 $0(Tier 1) MC
NOVAFERRUM PEDIATRIC DROPS $0(Tier 1) MC
nu-iron 150 $0(Tier 1) MC
nu-mag $0(Tier 1) MC
NUTRILYTE II $0(Tier 2) B/D
77 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML;
1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML;
1.25MEQ
$0(Tier 2) B/D
oceanic selenium $0(Tier 1) MC
oralyte $0(Tier 1) MC
oralyte freezer pops $0(Tier 1) MC
orazinc $0(Tier 1) MC
os-cal $0(Tier 1) MC
os-cal calcium + d3 $0(Tier 1) MC
os-cal extra d3 $0(Tier 1) MC
os-cal ultra $0(Tier 1) MC
osteo-poretical $0(Tier 1) MC
oysco 500 $0(Tier 1) MC
oysco 500+d tabs $0(Tier 1) MC
oysco d $0(Tier 1) MC
oyst-cal-d 500 $0(Tier 1) MC
oyster calcium $0(Tier 1) MC
oyster shell calcium + d $0(Tier 1) MC
oyster shell calcium + d3 $0(Tier 1) MC
oyster shell calcium + vitamin d $0(Tier 1) MC
oyster shell calcium 250+d $0(Tier 1) MC
oyster shell calcium 500 $0(Tier 1) MC
oyster shell calcium 500 + d tabs 500mg; 125unit $0(Tier 1) MC
oyster shell calcium 500+d $0(Tier 1) MC
oyster shell calcium 500/d $0(Tier 1) MC
oyster shell calcium plusvitamin d $0(Tier 1) MC
oyster shell calcium+d $0(Tier 1) MC
oyster shell calcium/d3 $0(Tier 1) MC
oyster shell calcium/d tabs 250mg; 125unit, 500mg; 200unit $0(Tier 1) MC
oyster shell calcium/vitamin d $0(Tier 1) MC
oyster shell calcium tabs 500mg $0(Tier 1) MC
oystercal-d $0(Tier 1) MC
pedialyte advanced care $0(Tier 1) MC
pedialyte freezer pops $0(Tier 1) MC
pedialyte singles soln 7meq/200ml; 5.3gm/200ml;
4meq/200ml; 9meq/200ml; 1.6mg/200ml, 8.3meq/240ml;
7.1meq/240ml; 4.7gm/240ml; 1.2gm/240ml; 4.7meq/240ml;
10.6meq/240ml
$0(Tier 1) MC
pedialyte soln 2.1meq/59ml; 1.5gm/59ml; 1.2meq/59ml;
2.7meq/59ml; 0.5mg/59ml, 35meq/l; 20gm/l; 5gm/l; 20meq/l;
45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l,
35meq/l; 30meq/l; 25gm/l; 20meq/l; 45meq/l
$0(Tier 1) MC
78 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
pediatric electrolyte $0(Tier 1) MC
pediatric electrolyte freeze pops $0(Tier 1) MC
pediatric electrolyte freezer pops soln 35meq/1000ml;
25gm/1000ml; 20meq/1000ml; 45meq/1000ml
$0(Tier 1) MC
pediatric electrolyte/zinc $0(Tier 1) MC
PERIKABIVEN $0(Tier 2) B/D
phospha 250 neutral $0(Tier 1)
PLENAMINE $0(Tier 2) B/D
poly-iron 150 $0(Tier 1) MC
polysacc iron 150 complex $0(Tier 1) MC
potassium chloride 0.15% /nacl 0.45% viaflex $0(Tier 1) B/D
potassium chloride 0.15% d5w/nacl 0.33% $0(Tier 1) B/D
potassium chloride 0.15% d5w/nacl 0.45% $0(Tier 1) B/D
potassium chloride 0.15% d5w/nacl 0.45% viaflex $0(Tier 1) B/D
potassium chloride 0.15% w/nacl 0.9% viaflex $0(Tier 1) B/D
potassium chloride 0.15%/d5w $0(Tier 1) B/D
potassium chloride 0.15%/nacl 0.9% $0(Tier 1) B/D
potassium chloride 0.22% d5w/nacl 0.45% $0(Tier 1) B/D
potassium chloride 0.224%/d5w/nacl 0.45% $0(Tier 1) B/D
potassium chloride 0.3%/ nacl 0.9% $0(Tier 1) B/D
potassium chloride 0.3%/d5w $0(Tier 1) B/D
potassium chloride 0.3%/nacl 0.9%/viaflex $0(Tier 1) B/D
potassium chloride cr tbcr 10meq $0(Tier 1)
potassium chloride cr tbcr 10meq $0(Tier 1) MO
potassium chloride er cpcr $0(Tier 1) MO
potassium chloride er tbcr 10meq, 20meq, 8meq $0(Tier 1)
potassium chloride er tbcr 10meq, 20meq $0(Tier 1) MO
potassium chloride sr tbcr 8meq $0(Tier 1)
potassium chloride sr tbcr 8meq $0(Tier 1) MO
potassium chloride oral soln $0(Tier 1)
potassium chloride pack $0(Tier 1) MO
POTASSIUM CHLORIDE INJ 10MEQ/100ML,
20MEQ/100ML, 40MEQ/100ML
$0(Tier 2) B/D
potassium chloride inj 2meq/ml $0(Tier 1) B/D
potassium citrate er $0(Tier 1)
PREMASOL $0(Tier 2) B/D
probarimin qt $0(Tier 1) MC
PROCALAMINE $0(Tier 2) B/D
profe $0(Tier 1) MC
proferrin es $0(Tier 1) MC
PROSOL $0(Tier 2) B/D
qc calcium fast dissolution $0(Tier 1) MC
79 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
ra calcium 600 $0(Tier 1) MC
ra calcium 600/vit d/minerals $0(Tier 1) MC
ra calcium citrate plus vitamin d-3 $0(Tier 1) MC
ra central-vite cardio $0(Tier 1) MC
ra central-vite performance $0(Tier 1) MC
ra central-vite under 50 mens $0(Tier 1) MC
ra central-vite under 50 womens $0(Tier 1) MC
ra central-vite womens mature $0(Tier 1) MC
ra natural magnesium $0(Tier 1) MC
ra pediatric electrolyte freezer pops $0(Tier 1) MC
ra pediatric electrolyte soln 35meq/l; 20gm/l; 5gm/l; 20meq/l;
45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l,
35meq/l; 30meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l;
30meq/l; 25gm/l; 20meq/l; 45meq/l
$0(Tier 1) MC
ra selenium natural $0(Tier 1) MC
ra selenium tabs 50mcg $0(Tier 1) MC
ra slow release iron $0(Tier 1) MC
ra zinc $0(Tier 1) MC
RINGERS INJECTION $0(Tier 2)
sb pediatric electrolyte $0(Tier 1) MC
se-tan plus $0(Tier 1) MC
selenium tbcr $0(Tier 1) MC
selenium tabs 200mcg, 50mcg $0(Tier 1) MC
slow fe $0(Tier 1) MC
slow release iron tbcr 45mg $0(Tier 1) MC
slow-mag $0(Tier 1) MC
sm balanced b-50 $0(Tier 1) MC
sm calcium 500/vitamin d3 $0(Tier 1) MC
sm calcium 600/vitamin d $0(Tier 1) MC
sm calcium citrate w/vitamin d3 $0(Tier 1) MC
sm calcium soft chews $0(Tier 1) MC
sm calcium/magnesium/zinc tabs 333mg; 133mg; 5mg $0(Tier 1) MC
sm calcium/vitamin d tabs 600mg; 400unit $0(Tier 1) MC
sm complete $0(Tier 1) MC
sm complete advanced formula $0(Tier 1) MC
sm complete senior formula $0(Tier 1) MC
sm iron tabs 325mg $0(Tier 1) MC
sm magnesium $0(Tier 1) MC
sm multiple vitamins essential $0(Tier 1) MC
sm multiple vitamins/iron $0(Tier 1) MC
sm oyster shell calcium/vitamin d3 $0(Tier 1) MC
sm oyster shell calcium/vitamin d tabs 500mg; 400unit $0(Tier 1) MC
80 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
sm pediatric electrolyte $0(Tier 1) MC
sm selenium $0(Tier 1) MC
sm slow release iron $0(Tier 1) MC
sm vit c/rose hips $0(Tier 1) MC
sm vitamin b-12 $0(Tier 1) MC
sm vitamin b-6 $0(Tier 1) MC
sm vitamin c $0(Tier 1) MC
sm vitamin e $0(Tier 1) MC
sm vitamin e blended $0(Tier 1) MC
sm zinc $0(Tier 1) MC
SODIUM CHLORIDE 0.45% $0(Tier 2)
SODIUM CHLORIDE INJ 0.9%, 2.5MEQ/ML, 3%, 5% $0(Tier 2)
sodium fluoride chew 0.5mg, 1mg $0(Tier 1)
sodium fluoride tabs 1mg $0(Tier 1)
super calcium 600 + d3 $0(Tier 1) MC
super calcium 600+d 400 $0(Tier 1) MC
super calcium 600+d3 400 $0(Tier 1) MC
super calcium tabs 600mg $0(Tier 1) MC
support $0(Tier 1) MC
TANDEM $0(Tier 1) MC
tandem plus $0(Tier 1) MC
taron forte $0(Tier 1) MC
th calcium $0(Tier 1) MC
th calcium 600 with vitamin d $0(Tier 1) MC
th calcium 600/vitamin d $0(Tier 1) MC
th calcium citrate/vitamin d $0(Tier 1) MC
th iron $0(Tier 1) MC
th oyster shell calcium/vitamin d $0(Tier 1) MC
th zinc $0(Tier 1) MC
therapeutic liquid $0(Tier 1) MC
theratrum complete tabs 60mg; 0; 30mcg; 150mcg; 162mg;
10mg; 72mg; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg;
150mcg; 250mcg; 100mg; 2mg; 20mg; 5mcg; 108mg; 80mg;
2mg; 1.7mg; 2mg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg;
30unit; 5000unit; 25mcg; 15mg
$0(Tier 1) MC
totalday multiple $0(Tier 1) MC
TPN ELECTROLYTES $0(Tier 2) B/D
TRAVASOL $0(Tier 2) B/D
TROPHAMINE $0(Tier 2) B/D
virt-phos 250 neutral $0(Tier 1)
wee care $0(Tier 1) MC
zinc 15 $0(Tier 1) MC
81 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
zinc chelated tabs 50mg $0(Tier 1) MC
zinc gluconate tabs 100mg, 30mg, 50mg $0(Tier 1) MC
zinc sulfate caps $0(Tier 1) MC
zinc sulfate tabs 220mg $0(Tier 1) MC
zinc-220 $0(Tier 1) MC
zinc oral lozg 100mg; 50mg; 500unit; 15mg $0(Tier 1) MC
zinc tabs 30mg, 50mg $0(Tier 1) MC
Therapeutic Nutrients/Minerals/Electrolytes
INTRALIPID INJ 20GM/100ML $0(Tier 2) B/D
NUTRILIPID $0(Tier 2) B/D
Vitamins
a-10000 $0(Tier 1) MC
abaneu-sl $0(Tier 1) MC
abc plus senior adults 50+ $0(Tier 1) MC
acerola c 500 $0(Tier 1) MC
actical $0(Tier 1) MC
active fe $0(Tier 1) MC
advanced stress formula/zinc $0(Tier 1) MC
alba-lybe nr $0(Tier 1) MC
animal chews chew 60mg; 0; 400unit; 4.5mcg; 300mcg;
10mg; 1.05mg; 1.2mg; 0; 1.05mg; 15unit; 1998unit
$0(Tier 1) MC
animal shapes + iron $0(Tier 1) MC
animal shapes chew 60mg; 0; 4.5mcg; 400unit; 300mcg;
13.5mg; 1.05mg; 1.2mg; 1.05mg; 15unit; 2500unit
$0(Tier 1) MC
antioxidant formula caps 250mg; 5000unit; 1mg; 1.5mg;
15mcg; 200unit; 7.5mg
$0(Tier 1) MC
apatate forte $0(Tier 1) MC
apetex $0(Tier 1) MC
apetigen $0(Tier 1) MC
apetigen-plus $0(Tier 1) MC
aquadeks $0(Tier 1) MC
aqueous vitamin d infants $0(Tier 1) MC
aqueous vitamin e $0(Tier 1) MC
ascorbic acid powd $0(Tier 1) MC
ascorbic acid tabs 250mg, 500mg $0(Tier 1) MC
b complete $0(Tier 1) MC
b complex/c tabs 300mg; 150mg; 10mg; 50mg; 5mg; 10.2mg;
15mg
$0(Tier 1) MC
b complex/folic acid $0(Tier 1) MC
b complex caps 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg;
60mg
$0(Tier 1) MC
b complex tabs $0(Tier 1) MC
82 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
b-12 tr $0(Tier 1) MC
b-12 tbcr $0(Tier 1) MC
b-12 subl 2500mcg $0(Tier 1) MC
b-12 tabs 100mcg, 500mcg, 50mcg $0(Tier 1) MC
b-1 tabs 100mg, 250mg $0(Tier 1) MC
b-2 $0(Tier 1) MC
b-50 complex tbcr 50mcg; 50mg; 50mcg; 400mcg; 50mcg;
50mg; 50mg; 30mg; 50mg; 50mg; 50mg
$0(Tier 1) MC
b-6 tabs 100mg, 50mg $0(Tier 1) MC
b-complex formula 1 $0(Tier 1) MC
b-complex plus vitamin c $0(Tier 1) MC
b-complex w/c tabs $0(Tier 1) MC
b-complex with b-12 $0(Tier 1) MC
b-complex caps 5mg; 1mcg; 400mcg; 60mg; 20mg; 0.5mg;
3mg; 3mg; 60mg, 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg;
3mg; 60mg
$0(Tier 1) MC
b-plex plus $0(Tier 1) MC
bacmin $0(Tier 1) MC
balance b-100 $0(Tier 1) MC
balance b-50 $0(Tier 1) MC
balanced b-100 tabs 100mcg; 100mg; 100mcg; 100mcg;
100mg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg
$0(Tier 1) MC
balanced b-50 complex tabs $0(Tier 1) MC
balanced b-50 tabs 50mcg; 50mg; 50mcg; 100mcg; 50mg;
50mg; 50mg; 50mg; 50mg; 50mg; 50mg
$0(Tier 1) MC
bee zee $0(Tier 1) MC
beta carotene caps 25000unit $0(Tier 1) MC
biocal $0(Tier 1) MC
biosupp $0(Tier 1) MC
biotin 5000 $0(Tier 1) MC
biotin/maximum strength $0(Tier 1) MC
biotin caps 2500mcg, 5000mcg $0(Tier 1) MC
biotin tabs 1000mcg, 300mcg $0(Tier 1) MC
biovol $0(Tier 1) MC
c 1000 $0(Tier 1) MC
c 1000/bioflavonoids/rosehips $0(Tier 1) MC
c 250 tabs $0(Tier 1) MC
c 500 $0(Tier 1) MC
c 500/rose hips tabs 500mg; 37mg $0(Tier 1) MC
c complex $0(Tier 1) MC
c-1000 $0(Tier 1) MC
c-1000 prolonged release $0(Tier 1) MC
83 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
c-1000/rose hips tabs 1000mg; 37mg $0(Tier 1) MC
c-250 tabs $0(Tier 1) MC
c-500 $0(Tier 1) MC
c-500 prolonged release $0(Tier 1) MC
c-500/rose hips tabs 500mg; 37mg $0(Tier 1) MC
calcium/c/d $0(Tier 1) MC
centravites $0(Tier 1) MC
centrum adults $0(Tier 1) MC
centrum kids complete $0(Tier 1) MC
centrum silver adult 50+ $0(Tier 1) MC
centrum silver ultra womens $0(Tier 1) MC
centrum silver tabs 60mg; 0; 30mcg; 220mg; 10mg; 72mg;
500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 0; 0; 50mg; 2.3mg;
20mg; 5mcg; 20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg;
2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit;
2500unit; 11mg
$0(Tier 1) MC
centrum specialist heart $0(Tier 1) MC
centrum ultra mens $0(Tier 1) MC
centrum chew $0(Tier 1) MC
centrum liqd 0; 60mg/15ml; 300mcg/15ml; 400unit/15ml;
25mcg/15ml; 6mcg/15ml; 0; 150mcg/15ml; 9mg/15ml;
2mg/15ml; 25mcg/15ml; 20mg/15ml; 10mg/15ml; 0;
2mg/15ml; 1.7mg/15ml; 0; 1.1mg/15ml; 1300unit/15ml;
30unit/15ml; 3mg/15ml
$0(Tier 1) MC
cerovite advanced formula $0(Tier 1) MC
cerovite jr $0(Tier 1) MC
certa plus tabs 90mg; 0; 30mcg; 10mg; 200mg; 72mg;
400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg; 250mcg;
300mcg; 100mg; 2.3mg; 20mg; 5mcg; 109mg; 25mcg; 80mg;
150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 11mg
$0(Tier 1) MC
certavite senior/antioxidant nutrients $0(Tier 1) MC
certavite/antioxidants $0(Tier 1) MC
chewable vitamin c chew 500mg $0(Tier 1) MC
chewable vite childrens $0(Tier 1) MC
chewable vite with iron/childrens $0(Tier 1) MC
childrens chewable multivitamin $0(Tier 1) MC
childrens chewable vitamin $0(Tier 1) MC
childrens chewable vitamins $0(Tier 1) MC
childrens chewable vitamins/iron chew 400unit; 4.5mcg;
15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg;
15unit; 2500unit
$0(Tier 1) MC
84 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
citrus calcium +d $0(Tier 1) MC
companion $0(Tier 1) MC
compete $0(Tier 1) MC
complete $0(Tier 1) MC
complex b-100 tbcr 100mcg; 100mg; 100mg; 100mcg;
200mcg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg
$0(Tier 1) MC
corvita $0(Tier 1) MC
corvite $0(Tier 1) MC
corvite 150 $0(Tier 1) MC
corvite fe tabs 160mg; 5mg; 1000unit; 10mg; 15mg; 1mg;
150mg; 10mg; 25mg
$0(Tier 1) MC
corvite free $0(Tier 1) MC
cranberry urinary comfort $0(Tier 1) MC
cvs b complex plus c $0(Tier 1) MC
cvs b-1 $0(Tier 1) MC
cvs b-12 liqd, tabs $0(Tier 1) MC
cvs b-6 $0(Tier 1) MC
cvs balanced b-100 $0(Tier 1) MC
cvs balanced b-50 $0(Tier 1) MC
cvs beta carotene $0(Tier 1) MC
cvs biotin high potency $0(Tier 1) MC
cvs biotin caps 5000mcg $0(Tier 1) MC
cvs calcium $0(Tier 1) MC
cvs calcium/magnesium/zinc $0(Tier 1) MC
cvs childrens chewable complete $0(Tier 1) MC
cvs childrens chewable multivitamin/iron $0(Tier 1) MC
cvs daily energy $0(Tier 1) MC
cvs daily multiple $0(Tier 1) MC
cvs daily multiple for men $0(Tier 1) MC
cvs daily multiple for men 50+ $0(Tier 1) MC
cvs daily multiple for women $0(Tier 1) MC
cvs daily multiple for women 50+ $0(Tier 1) MC
cvs daily multiple plus iron/calcium/zinc $0(Tier 1) MC
cvs e oil $0(Tier 1) MC
cvs gummy dinos chew 30mg; 75mcg; 5mg; 200unit; 38mg;
5mcg; 200mcg; 20mcg; 40mcg; 1mg; 20unit; 2000unit; 2.5mg
$0(Tier 1) MC
cvs hair skin & nails/an tioxidants $0(Tier 1) MC
cvs spectravite adult 50+ tabs $0(Tier 1) MC
cvs spectravite advanced formula $0(Tier 1) MC
85 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
cvs spectravite senior tabs 60mg; 0; 30mcg; 150mcg; 220mg;
10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg; 1.5mg;
50unit; 2500unit; 11mg
$0(Tier 1) MC
cvs spectravite ultra health mens $0(Tier 1) MC
cvs spectravite ultra mens health $0(Tier 1) MC
cvs spectravite ultra women $0(Tier 1) MC
cvs spectravite ultra womens health $0(Tier 1) MC
cvs spectravite ultra womens health senior $0(Tier 1) MC
cvs super b complex/c $0(Tier 1) MC
cvs vitamin a $0(Tier 1) MC
cvs vitamin b-12 $0(Tier 1) MC
cvs vitamin b-12 tr $0(Tier 1) MC
cvs vitamin b-6 $0(Tier 1) MC
cvs vitamin c/rose hips $0(Tier 1) MC
cvs vitamin c chew $0(Tier 1) MC
cvs vitamin c tabs 1000mg, 500mg $0(Tier 1) MC
cvs vitamin e $0(Tier 1) MC
daily combo multi vitamin $0(Tier 1) MC
daily multiple vitamin/iron tabs 3mcg; 250mg; 30mg; 2mg;
0.5mg; 5mg; 75mg; 5mg
$0(Tier 1) MC
daily multiple vitamins $0(Tier 1) MC
daily multiple vitamin tabs 60mg; 0; 45mg; 10mg; 400unit;
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit
$0(Tier 1) MC
daily value multivitamin $0(Tier 1) MC
daily vitamin $0(Tier 1) MC
daily vitamin formula+ir on $0(Tier 1) MC
daily vitamin formula+iron tabs 60mg; 13mg; 10mg; 400unit;
6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 15unit;
5000unit
$0(Tier 1) MC
daily vitamin formula+minerals tabs 50mg; 1mg; 15.8mg;
400unit; 5mcg; 1mcg; 4.5mg; 10mg; 1mg; 20mg; 11.6mg;
150mcg; 1mg; 2.5mg; 5mcg; 2mg; 5000unit; 3.75mg
$0(Tier 1) MC
daily vitamins $0(Tier 1) MC
daily vite $0(Tier 1) MC
daily vite with iron $0(Tier 1) MC
daily-vite/iron/beta-carotene $0(Tier 1) MC
daily-vite tabs 60mg; 0; 45mg; 0; 10mg; 0; 400unit; 6mcg;
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit, 60mg;
400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 5000unit
$0(Tier 1) MC
dekas essential caps $0(Tier 1) MC
86 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
dekas plus caps, liqd $0(Tier 1) MC
dialyvite 800 $0(Tier 1) MC
dialyvite 800/iron $0(Tier 1) MC
dino-life $0(Tier 1) MC
dino-life w extra c $0(Tier 1) MC
dino-life w/iron & zinc $0(Tier 1) MC
DRISDOL CAPS $0(Tier 1) MC
e-400 $0(Tier 1) MC
e-oil $0(Tier 1) MC
e400 mixed $0(Tier 1) MC
ecee plus $0(Tier 1) MC
eql one daily essential tabs 60mg; 0; 6mcg; 400mcg; 20mg;
10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit
$0(Tier 1) MC
ergocalciferol soln $0(Tier 1) MC
essentia $0(Tier 1) MC
essential balance $0(Tier 1) MC
flintstones complete chew 0; 40mcg; 10mg; 100mg; 400unit;
38mg; 2mg; 6mcg; 18mg; 400mcg; 20mg; 15mg; 100mg;
150mcg; 2mg; 1.7mg; 60mg; 1.5mg; 3000unit; 30unit; 12mg,
60mg; 0; 40mcg; 100mg; 10mg; 38mg; 2mg; 6mcg; 18mg;
400mcg; 20mg; 15mg; 100mg; 150mcg; 2mg; 1.7mg; 10mg;
1.5mg; 3000unit; 400unit; 30unit; 12mg
$0(Tier 1) MC
flintstones plus extra c $0(Tier 1) MC
flintstones/my first $0(Tier 1) MC
folic acid inj $0(Tier 1) MC
folic acid tabs 1mg $0(Tier 1) MC
folitab 500 $0(Tier 1) MC
foltabs 800 $0(Tier 1) MC
fortavit caps $0(Tier 1) MC
fosfree $0(Tier 1) MC
fruit c 500 $0(Tier 1) MC
fruity c $0(Tier 1) MC
fruity chewables multivitamin $0(Tier 1) MC
full spectrum b/vitamin c $0(Tier 1) MC
gnp animal shapes $0(Tier 1) MC
gnp animal shapes plus extra c $0(Tier 1) MC
gnp animal shapes plus iron $0(Tier 1) MC
gnp b-50 balanced tabs 50mcg; 50mg; 50mcg; 400mcg;
50mg; 50mg; 50mg; 50mg
$0(Tier 1) MC
87 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
gnp century adults 50+ senior tabs 60mg; 0; 30mcg; 220mg;
10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;
250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;
150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;
1.5mg; 50unit; 2500unit; 11mg
$0(Tier 1) MC
gnp century cardio healthformula tabs 90mg; 0; 30mcg;
40mg; 10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg;
400mcg; 100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg;
150mcg; 6mg; 3.4mg; 2mg; 150mcg; 10mcg; 75mcg; 70mcg;
10mcg; 3mg; 60unit; 5000unit; 15mg
$0(Tier 1) MC
gnp century ultimate mens complete $0(Tier 1) MC
gnp century ultimate womens complete $0(Tier 1) MC
gnp century ultimate womens senior formula $0(Tier 1) MC
gnp century tabs 60mg; 0; 30mcg; 200mg; 10mg; 72mg;
400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg;
20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg
$0(Tier 1) MC
gnp childrens chewables/extra c $0(Tier 1) MC
gnp childrens chewables/iron $0(Tier 1) MC
gnp essential one daily tabs 60mg; 0; 75mg; 10mg; 400unit;
6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
$0(Tier 1) MC
gnp hair/skin/nails tabs 60mg; 1250mcg; 0.5mg; 100mg;
100unit; 50mg; 30unit; 1mg; 100mcg; 50mg; 250mcg; 25mg;
50mg; 10mg; 50mg; 0.85mg; 0.75mg; 2500unit; 7.5mg
$0(Tier 1) MC
gnp little ones childrens $0(Tier 1) MC
gnp mega multi for men $0(Tier 1) MC
gnp mega multi for women $0(Tier 1) MC
gnp one daily maximum $0(Tier 1) MC
gnp one daily mens health 50+ $0(Tier 1) MC
gnp one daily plus iron tabs 60mg; 75mg; 10mg; 400unit;
6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit
$0(Tier 1) MC
gnp one daily womens health 50+ $0(Tier 1) MC
gnp opti-vitamins tabs 200mg; 1000unit; 2mg; 2mg; 55mcg;
60unit; 40mg
$0(Tier 1) MC
gnp vitamin a caps 8000unit $0(Tier 1) MC
gnp vitamin c tr $0(Tier 1) MC
gnp vitamin c w/rose hips tr $0(Tier 1) MC
gnp vitamin c w/rose hips tabs 500mg $0(Tier 1) MC
gnp vitamin c tabs 500mg $0(Tier 1) MC
gnp zoochews gummies $0(Tier 1) MC
88 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
halls defense vitamin c drops $0(Tier 1) MC
hard nails $0(Tier 1) MC
honey bears $0(Tier 1) MC
honey bears w/iron and zinc $0(Tier 1) MC
icaps areds formula $0(Tier 1) MC
icaps mv $0(Tier 1) MC
icaps plus $0(Tier 1) MC
integra $0(Tier 1) MC
integra f $0(Tier 1) MC
integra plus $0(Tier 1) MC
iron 100/c $0(Tier 1) MC
iron supplement childrens $0(Tier 1) MC
iron tabs 27mg $0(Tier 1) MC
kobee $0(Tier 1) MC
kp adults 50+ daily formula $0(Tier 1) MC
kp adults daily formula $0(Tier 1) MC
kp b complex/c $0(Tier 1) MC
kp mens 50+ daily formula $0(Tier 1) MC
kp mens daily formula $0(Tier 1) MC
kp vitamin e $0(Tier 1) MC
kp womens 50+ daily formula $0(Tier 1) MC
kp womens daily formula $0(Tier 1) MC
l-methyl-b6-b12 $0(Tier 1) MC
life pack mens $0(Tier 1) MC
life pack womens $0(Tier 1) MC
lysiplex plus liqd $0(Tier 1) MC
mega multiple w/chelated minerals $0(Tier 1) MC
mega multivitamin for men $0(Tier 1) MC
mega multivitamin for women $0(Tier 1) MC
MEPHYTON $0(Tier 1) MC
meribin $0(Tier 1) MC
mtx support $0(Tier 1) MC
multi complete/iron $0(Tier 1) MC
multi vitamin daily $0(Tier 1) MC
multi-day plus iron $0(Tier 1) MC
multi-day vitamins $0(Tier 1) MC
multi-delyn $0(Tier 1) MC
multi-delyn/iron $0(Tier 1) MC
multi-vitamin daily $0(Tier 1) MC
multi-vitamin hp/minerals $0(Tier 1) MC
multi-vitamin/minerals $0(Tier 1) MC
multi-vitamins $0(Tier 1) MC
89 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
multi-vitamin tabs 60mg; 0; 30mcg; 10mg; 400unit; 6mcg;
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit
$0(Tier 1) MC
multilex $0(Tier 1) MC
multilex-t&m $0(Tier 1) MC
multiple vitamin/minerals/no iron $0(Tier 1) MC
multiple vitamins plain $0(Tier 1) MC
multiple vitamins/iron chew $0(Tier 1) MC
multiple vitamins tabs 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg;
2mg; 5000unit; 400unit, 60mg; 20mg; 8mcg; 1.7mg; 1.5mg;
5000unit; 400unit; 30unit
$0(Tier 1) MC
multivitamin & mineral $0(Tier 1) MC
my-vitalife $0(Tier 1) MC
mykidz iron $0(Tier 1) MC
mykidz iron 10 $0(Tier 1) MC
nephro-vite $0(Tier 1) MC
nephrocaps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg;
10mg; 1.7mg; 1.5mg
$0(Tier 1) MC
nephronex liqd $0(Tier 1) MC
niacin er cpcr 250mg $0(Tier 1) MC
niacin sr cpcr 250mg $0(Tier 1) MC
niacin tr cpcr 250mg $0(Tier 1) MC
niacin tr tbcr 250mg, 500mg $0(Tier 1) MC
niacin cpcr 250mg $0(Tier 1) MC
no iron multiple vitamin/minerals $0(Tier 1) MC
nutricap $0(Tier 1) MC
nutrivit $0(Tier 1) MC
omnicap $0(Tier 1) MC
once daily/iron $0(Tier 1) MC
once daily tabs 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 2mg;
5000unit; 400unit
$0(Tier 1) MC
oncovite $0(Tier 1) MC
one daily complete $0(Tier 1) MC
one daily maximum $0(Tier 1) MC
one daily mens tabs 90mg; 0; 30mcg; 210mg; 120mcg; 2mg;
3mg; 400mcg; 0.6mg; 120mg; 2mg; 16mg; 5mg; 99mg;
1.7mg; 105mcg; 1.2mg; 3500unit; 18mcg; 400unit; 45unit;
20mcg; 15mg
$0(Tier 1) MC
one daily plus iron $0(Tier 1) MC
one daily plus minerals $0(Tier 1) MC
one daily womens 50+ $0(Tier 1) MC
one daily/iron/calcium $0(Tier 1) MC
one daily/minerals $0(Tier 1) MC
90 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
one daily tabs 60mg; 0; 6mcg; 400mcg; 20mg; 10mg; 2mg;
1.7mg; 1.5mg; 5000unit; 400unit; 30unit
$0(Tier 1) MC
one-a-day essential $0(Tier 1) MC
one-a-day mens 50+ advantage $0(Tier 1) MC
one-a-day teen advantage for her $0(Tier 1) MC
one-a-day teen advantage for him $0(Tier 1) MC
one-a-day womens formula $0(Tier 1) MC
one-daily multi vitamins $0(Tier 1) MC
pa b-complex with b-12 $0(Tier 1) MC
pa biotin caps $0(Tier 1) MC
pa oyster shell calcium $0(Tier 1) MC
pa vitamin b-12 tr $0(Tier 1) MC
pa vitamin e $0(Tier 1) MC
peridin-c $0(Tier 1) MC
poly vitamin $0(Tier 1) MC
poly-vita drops $0(Tier 1) MC
poly-vita/iron drops $0(Tier 1) MC
polyvitamin $0(Tier 1) MC
polyvitamin/iron $0(Tier 1) MC
prevent $0(Tier 1) MC
protectiron $0(Tier 1) MC
protexin $0(Tier 1) MC
pure c 500 $0(Tier 1) MC
pureway-c $0(Tier 1) MC
pyridoxine hcl tabs $0(Tier 1) MC
qc calcium/minerals/vitamin d $0(Tier 1) MC
qc childrens chewable vitamins/extra c $0(Tier 1) MC
qc maximum daily multivitamin/multimineral $0(Tier 1) MC
qc multi-vite $0(Tier 1) MC
qc womens daily multivitamin $0(Tier 1) MC
quintabs-m tabs 0; 30mcg; 30mg; 300mg; 30mg; 0.2mg;
30mcg; 50unit; 400unit; 400mcg; 15mg; 2mg; 100mg;
150mcg; 30mg; 30mg; 35mcg; 30mg; 5000unit; 7.5mg
$0(Tier 1) MC
ra b-complex $0(Tier 1) MC
ra b-complex with b-12 $0(Tier 1) MC
ra b-complex/vitamin c tr $0(Tier 1) MC
ra balanced b-100 $0(Tier 1) MC
ra balanced b-50 $0(Tier 1) MC
ra beta carotene $0(Tier 1) MC
ra biotin caps $0(Tier 1) MC
ra calcium 600 plus vitamin d-3 $0(Tier 1) MC
ra calcium soft chews $0(Tier 1) MC
91 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
ra calcium/boron $0(Tier 1) MC
ra calcium/magnesium/zinc/copper $0(Tier 1) MC
ra central-vite $0(Tier 1) MC
ra central-vite energy $0(Tier 1) MC
ra central-vite select mature $0(Tier 1) MC
ra central-vite senior $0(Tier 1) MC
ra central-vite/antioxidants tabs 60mg; 0; 30mcg; 162mg;
10mg; 72mg; 120mcg; 2mg; 6mcg; 400unit; 18mg; 400mcg;
250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg;
80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg;
20mcg; 10mcg; 1.5mg; 30unit; 3500unit; 15mg
$0(Tier 1) MC
ra coral calcium $0(Tier 1) MC
ra hi cal $0(Tier 1) MC
ra hi-cal plus vitamin d $0(Tier 1) MC
ra high potency iron $0(Tier 1) MC
ra iron $0(Tier 1) MC
ra magnesium $0(Tier 1) MC
ra natural vitamin e $0(Tier 1) MC
ra niacin $0(Tier 1) MC
ra one daily energy formula $0(Tier 1) MC
ra one daily essential $0(Tier 1) MC
ra one daily maximum $0(Tier 1) MC
ra one daily mens 50+ with vitamin d-3 $0(Tier 1) MC
ra one daily multi-vitamin $0(Tier 1) MC
ra one daily multi-vitamin plus iron $0(Tier 1) MC
ra oyster shell calcium/vitamin d $0(Tier 1) MC
ra stress formula advanced $0(Tier 1) MC
ra stress formula energy $0(Tier 1) MC
ra therapeutic m plus beta carotene $0(Tier 1) MC
ra vitamin a $0(Tier 1) MC
ra vitamin b-1 $0(Tier 1) MC
ra vitamin b-12 tr $0(Tier 1) MC
ra vitamin b-12 tabs $0(Tier 1) MC
ra vitamin b-6 $0(Tier 1) MC
ra vitamin b12 $0(Tier 1) MC
ra vitamin c drops $0(Tier 1) MC
ra vitamin c tr $0(Tier 1) MC
ra vitamin c/acerola $0(Tier 1) MC
ra vitamin c/rose hips $0(Tier 1) MC
ra vitamin c/rose hips tr $0(Tier 1) MC
ra vitamin c chew 500mg; 0 $0(Tier 1) MC
ra vitamin c tabs $0(Tier 1) MC
92 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
ra vitamin e $0(Tier 1) MC
ra whole source complete formula for men $0(Tier 1) MC
ra whole source dietary $0(Tier 1) MC
ra whole source dietary for men $0(Tier 1) MC
ra whole source dietary mature $0(Tier 1) MC
rabano yodado $0(Tier 1) MC
rena-vite $0(Tier 1) MC
renal vitamin $0(Tier 1) MC
renal-vite $0(Tier 1) MC
risacal-d $0(Tier 1) MC
scooby-doo one a day $0(Tier 1) MC
senior tabs $0(Tier 1) MC
sentry senior $0(Tier 1) MC
sentry tabs 60mg; 0; 30mcg; 75mcg; 200mg; 10mg; 20mg;
72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg;
2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;
2mg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;
3500unit; 11mg, 90mg; 0; 30mcg; 150mcg; 200mg; 10mg;
109mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg;
250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg; 25mcg;
80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 11mg
$0(Tier 1) MC
siderol $0(Tier 1) MC
slo-niacin tbcr 250mg, 500mg $0(Tier 1) MC
sm chewable c $0(Tier 1) MC
sm super b complex-vitamin c $0(Tier 1) MC
sm vitamin c/rose hips $0(Tier 1) MC
stress b/zinc $0(Tier 1) MC
stress formula w/iron $0(Tier 1) MC
stress formula/iron tabs 500mg; 45mcg; 12mcg; 27mg;
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit
$0(Tier 1) MC
stress formula/zinc tabs 500mg; 45mcg; 3mg; 12mcg;
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg,
600mg; 45mg; 3mg; 12mcg; 400mcg; 100mg; 20mg; 5mg;
10mg; 15mg; 30unit; 23.9mg
$0(Tier 1) MC
stress formula tabs 500mg; 45mcg; 12mcg; 400mcg; 100mg;
20mg; 3mg; 10mg; 10mg; 30unit, 500mg; 45mcg; 12mcg;
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit
$0(Tier 1) MC
strovite forte tabs $0(Tier 1) MC
strovite one $0(Tier 1) MC
super b complex maxi $0(Tier 1) MC
super b complex/c $0(Tier 1) MC
93 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
super b with c $0(Tier 1) MC
super biotin caps $0(Tier 1) MC
super quints b-50 $0(Tier 1) MC
super thera vite m $0(Tier 1) MC
superplex-t $0(Tier 1) MC
supervite ec $0(Tier 1) MC
suplevit $0(Tier 1) MC
support-500 $0(Tier 1) MC
tab-a-vite $0(Tier 1) MC
tab-a-vite maximum $0(Tier 1) MC
tab-a-vite w/beta carotene $0(Tier 1) MC
tab-a-vite womens $0(Tier 1) MC
tab-a-vite/iron $0(Tier 1) MC
th b 100 complex $0(Tier 1) MC
th b complex/iron/vitamin c/vitamin e $0(Tier 1) MC
th complete multi $0(Tier 1) MC
th complete multi 50+ $0(Tier 1) MC
th daily multiple vitamins $0(Tier 1) MC
th daily multiple vitamins/iron $0(Tier 1) MC
th premium daily multiple $0(Tier 1) MC
th theradex-m $0(Tier 1) MC
th vitamin b 50/b-complex $0(Tier 1) MC
th vitamin b-12 $0(Tier 1) MC
th vitamin b-6 $0(Tier 1) MC
th vitamin b1 $0(Tier 1) MC
th vitamin b12 $0(Tier 1) MC
th vitamin b12 er $0(Tier 1) MC
th vitamin c $0(Tier 1) MC
th vitamin c/rose hips/bioflavonoids $0(Tier 1) MC
th vitamin e/d-alpha $0(Tier 1) MC
th vitamin e caps 200unit, 400unit $0(Tier 1) MC
thera m plus $0(Tier 1) MC
94 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
thera-m tabs 120mg; 15mcg; 44mg; 10mg; 7.5mg; 400unit;
15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg;
31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg;
30unit; 5500unit; 15mg, 90mg; 0; 30mcg; 150mcg; 40mg;
7.5mg; 26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg;
3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg;
3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit;
30unit; 28mcg; 15mg, 90mg; 0; 30mcg; 30mg; 10mg; 50mcg;
2mg; 12mcg; 400unit; 9mg; 400mcg; 100mg; 2mg; 20mg;
5mcg; 23mg; 28mcg; 7.5mg; 7mg; 150mcg; 6mg; 3.4mg;
6mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit;
5000unit; 15mg
$0(Tier 1) MC
thera-tabs $0(Tier 1) MC
thera/beta-carotene $0(Tier 1) MC
thera tabs 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3mg;
3.4mg; 3mg; 5000unit; 400unit; 30unit
$0(Tier 1) MC
theratrum complete tabs 60mg; 0; 30mcg; 150mcg; 162mg; 0;
10mg; 0; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg;
250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg;
80mg; 72mg; 150mcg; 2mg; 1.7mg; 2mg; 0; 10mcg; 75mcg;
20mcg; 10mcg; 1.5mg; 30unit; 3500unit; 15mg
$0(Tier 1) MC
therems $0(Tier 1) MC
therems-h $0(Tier 1) MC
therems-m $0(Tier 1) MC
thiamine hcl tabs 100mg $0(Tier 1) MC
total b/c $0(Tier 1) MC
tri-vi-sol $0(Tier 1) MC
tri-vita $0(Tier 1) MC
tri-vitamin $0(Tier 1) MC
unicomplex-m $0(Tier 1) MC
v-c forte $0(Tier 1) MC
vic-forte $0(Tier 1) MC
vita-bee/c $0(Tier 1) MC
vitalee $0(Tier 1) MC
vitalets childrens chew 40mg; 0; 150mcg; 80mg; 5mg; 3mcg;
200unit; 10mg; 200mcg; 20mg; 0.1mg; 10mg; 60mg; 1mg;
0.85mg; 0.75mg; 15unit; 2500unit; 0.8mg
$0(Tier 1) MC
vitalets chew 40mg; 0; 150mcg; 80mg; 3mcg; 200unit; 10mg;
200mcg; 20mg; 0.1mg; 10mg; 5mg; 60mg; 1mg; 0.85mg;
0.75mg; 2500unit; 15unit; 0.8mg
$0(Tier 1) MC
vitamin a caps 10000unit, 8000unit $0(Tier 1) MC
vitamin b 6 $0(Tier 1) MC
95 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step
Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D
drugs or OTC items covered by Medicaid.
Name of drug
What the drug
will cost you
(tier level)
Necessary actions,
restrictions, or limits on
use
vitamin b complex-c $0(Tier 1) MC
vitamin b complex tabs 10mg; 10mg; 0.2mg; 2mg; 1.5mg,
2mcg; 15mg; 5mg; 2mg; 2mg; 2mg
$0(Tier 1) MC
vitamin b-1 $0(Tier 1) MC
vitamin b-12 tr tbcr 1000mcg $0(Tier 1) MC
vitamin b-12 subl 2500mcg $0(Tier 1) MC
vitamin b-12 tabs 1000mcg, 100mcg, 250mcg, 500mcg $0(Tier 1) MC
vitamin b-2 $0(Tier 1) MC
vitamin b-6 tabs 100mg, 25mg, 50mg $0(Tier 1) MC
vitamin b-complex $0(Tier 1) MC
vitamin b1 $0(Tier 1) MC
vitamin b12 tabs, tbcr $0(Tier 1) MC
vitamin c sr $0(Tier 1) MC
vitamin c tr/rose hips $0(Tier 1) MC
vitamin c tr cpcr $0(Tier 1) MC
vitamin c tr tbcr 1500mg, 500mg $0(Tier 1) MC
vitamin c/rose hips tabs 1000mg, 1000mg; 0, 500mg, 500mg;
0
$0(Tier 1) MC
vitamin c chew 0; 500mg; 0; 0; 0; 0, 250mg, 500mg $0(Tier 1) MC
vitamin c powd, syrp, tbcr $0(Tier 1) MC
vitamin c tabs 1000mg, 250mg, 500mg $0(Tier 1) MC
vitamin d caps 50000unit $0(Tier 1) MC
vitamin e water dispersible $0(Tier 1) MC
vitamin e water soluble caps 400unit $0(Tier 1) MC
vitamin e-400 $0(Tier 1) MC
vitamin e/d-alpha natural caps 400unit $0(Tier 1) MC
vitamin e/d-alpha caps 1000unit, 400unit $0(Tier 1) MC
vitamin e caps 1000unit, 100unit, 200unit, 400unit $0(Tier 1) MC
vitamin k1 inj 10mg/ml $0(Tier 1) MC
vitamins & minerals $0(Tier 1) MC
vitamins for hair tabs 400mcg; 100mg; 250mg; 2mg; 6mcg;
18mg; 400mcg; 125mg; 150mcg; 5mg; 100mg; 15mg
$0(Tier 1) MC
vitatrum chew $0(Tier 1) MC
vitrum 50+ senior multi $0(Tier 1) MC
VP-PNV-DHA $0(Tier 2)
womens biomultiple $0(Tier 1) MC
womens daily formula $0(Tier 1) MC
womens daily formula/folic acid/calcium/iron $0(Tier 1) MC
womens one daily $0(Tier 1) MC
yelets teenage formula $0(Tier 1) MC
zoo friends $0(Tier 1) MC
zoo friends plus iron $0(Tier 1) MC
96
Index Drug Name Page #
12 hour decongestant 65
a-10000 81
abacavir 27
abacavir sulfate/lamivudine/zidovudine 27
abacavir/lamivudine 27
abaneu-sl 81
abc plus senior adults 50+ 81
ABELCET 15
ABILIFY DISCMELT 24
ABILIFY MAINTENA 24
ABRAXANE 19
acamprosate calcium dr 5
acarbose 29
acebutolol hcl 34
acephen 1
acerola c 500 81
aceta-gesic 62
acetaminophen 1
acetaminophen/caffeine/dihydrocodeine 3
acetaminophen/codeine 3
acetaminophen/codeine #2 3
acetaminophen/codeine #3 3
acetaminophen/codeine #4 3
acetaminophen/codeine phosphate 3
acetaminophen/diphenhydramine 62
acetasol hc 61
acetazolamide 36
acetazolamide er 61
acetazolamide sodium 36
acetic acid 61
acetic acid/aluminum acetate 61
acetylcysteine 65
acid gone 41
acid reducer maximum strength 41
acitretin 39
acne medication 10 39
acne medication 5 39
ACTHIB 55
actical 81
ACTIDOSE/SORBITOL 41
ACTIMMUNE 55
active 1st blood lancets 30g/easy twist cap 57
active fe 81
Drug Name Page #
acyclovir 29
acyclovir sodium 29
ADACEL 55
ADAGEN 40
adefovir dipivoxil 26
ADEMPAS 65
adrucil 19
advanced stress formula/zinc 81
aerovent plus holding chamber/collapsible 57
afeditab cr 34
AFINITOR 21
AFINITOR DISPERZ 21
AGGRENOX 32
a-hydrocort 46
ak-poly-bac 6
akwa tears 59
ala cort 46
ALA SCALP 46
ALAHIST DM 65
ALA-HIST IR 62
ALA-HIST PE 62
alba-lybe nr 81
ALBENZA 23
albuterol 64
albuterol sulfate 64
albuterol sulfate er 64
alclometasone dipropionate 46
alcohol prep pads 6
ALDURAZYME 40
ALECENSA 21
alendronate sodium 57
alfuzosin hcl er 45
ALIMTA 19
ALINIA 23
all day allergy 62
all day allergy childrens 62
all day allergy-d 62
all day pain relief 1
all day relief 1
aller-chlor 62
allergy 62
allergy relief 62
allergy relief child 62
allergy relief d-24 62
all-nite cold & flu nighttime relief 65
all-nite multi-symptom cold/flu relief 66
allopurinol 17
97
Drug Name Page #
almacone 41
almacone double strength 41
ALOCRIL 60
ALOPRIM 17
ALORA 48
alosetron hydrochloride 44
ALOXI 15
alprazolam 29
alprazolam odt 29
altavera 48
aluminum hydroxide 41
alyacen 1/35 48
alyacen 7/7/7 49
amantadine hcl 28
AMBISOME 16
amcinonide 46
amethia 49
amethia lo 49
amifostine 19
amikacin sulfate 6
amiloride hcl 36
amiloride/hydrochlorothiazide 36
aminophylline 65
AMINOSYN 71
AMINOSYN 7%/ELECTROLYTES 71
AMINOSYN 8.5%/ELECTROLYTES 71
AMINOSYN II 71
AMINOSYN II 8.5%/ELECTROLYTES 71
AMINOSYN M 71
AMINOSYN-HBC 71
AMINOSYN-PF 71
AMINOSYN-PF 7% 71
AMINOSYN-RF 71
amiodarone hcl 33
AMITIZA 44
amitriptyline hcl 14
amlodipine besylate 35
amlodipine besylate/benazepril
hydrochloride
35
amlodipine besylate/valsartan 35
amlodipine/valsartan/hctz 35
ammonium lactate 39
amnesteem 39
amoxapine 15
amoxicillin 9
amoxicillin/clavulanate potassium 9
amoxicillin/clavulanate potassium er 9
Drug Name Page #
amphetamine/dextroamphetamine 37
amphotericin b 16
ampicillin 9
ampicillin sodium 9
ampicillin-sulbactam 9
AMPYRA 38
ANADROL-50 48
anagrelide hydrochloride 32
anaspaz 41
anastrozole 21
ANDROGEL 48
ANDROGEL PUMP 48
ANDROXY 48
animal chews 81
animal shapes 81
animal shapes + iron 81
antacid calcium extra st rength 41
antacid calcium regular strength 41
antacid extra strength 41
antacid maximum strength 41
antacid plus anti-gas relief 41
anti-diarrheal 41
antifungal 16
anti-fungal powder 16
anti-nausea 41
antioxidant formula 81
anu-med 41
apatate forte 81
apetex 81
apetigen 81
apetigen-plus 81
ap-hist dm 66
APOKYN 23
apraclonidine 61
apri 49
APRISO 56
aprodine 66
APTIOM 11
APTIVUS 28
aquadeks 81
aqueous vitamin d infants 81
aqueous vitamin e 81
ARALAST NP 66
aranelle 49
ARANESP ALBUMIN FREE 32
ARCALYST 55
aripiprazole 24
98
Drug Name Page #
aripiprazole odt 24
ARISTADA 24
armodafinil 70
ARRANON 19
artificial tears 60
ARZERRA 22
ascomp/codeine 3
ascorbic acid 81
aspirin 1
aspirin 32
aspirin adult low strength 32
aspirin ec 1
aspirin ec 32
aspirin ec low dose 32
aspirin low dose 32
aspirin/dipyridamole 32
aspir-low 32
assure prism multi test strips 57
ASTAGRAF XL 54
atenolol 34
atenolol/chlorthalidone 34
ATGAM 55
atorvastatin calcium 36
atovaquone 23
atovaquone/proguanil hcl 23
ATRIPLA 28
atropine sulfate 41
atropine sulfate 60
ATROVENT HFA 64
aubra 49
augmented betamethasone dipropionate 46
AUGMENTIN 9
AURYXIA 46
AVASTIN 22
AVELOX 10
aviane 49
AVODART 45
AVONEX 38
AVONEX PEN 38
azacitidine 19
AZACTAM IN ISO-OSMOTIC
DEXTROSE
8
AZASAN 54
AZASITE 9
azathioprine 54
azelastine hcl 60
azelastine hcl 62
Drug Name Page #
AZILECT 24
azithromycin 9
AZOPT 61
aztreonam 8
azurette 49
b complete 81
b complex 81
b complex/c 81
b complex/folic acid 81
b-1 82
b-12 82
b-12 tr 82
b-2 82
b-50 complex 82
b-6 82
baby darlings pediatric electrolyte 71
baciim 6
bacitracin 6
bacitracin zinc 6
bacitracin/neomycin/polymyxin 6
bacitracin/polymyxin b 6
baclofen 26
bacmin 82
BACTROBAN NASAL 6
balance b-100 82
balance b-50 82
balanced b-100 82
balanced b-50 82
balanced b-50 complex 82
balsalazide disodium 57
balziva 49
banophen 62
BANZEL 12
BARACLUDE 26
b-complex 82
b-complex formula 1 82
b-complex plus vitamin c 82
b-complex w/c 82
b-complex with b-12 82
bd autoshield duo 30g x 3/16" 57
bd eclipse syringe/1ml/30gx1/2" 57
bd insulin syringe safetyglide/1ml/29g x
1/2"
57
bd insulin syringe ultrafine/0.3ml/31g x
5/16"
58
bd insulin syringe ultrafine/0.5ml/30g x 1/2" 58
bd insulin syringe ultrafine/1ml/31g x 5/16" 58
99
Drug Name Page #
bd pen needle/mini/ultrafine/31g x 3/16" 58
bd pen needle/nano/ultra fine/32g x 4mm 58
bd pen needle/ultrafine/29g x 12.7mm 58
bd safetyglide 27g x 5/8" 58
bee zee 82
bekyree 49
BELEODAQ 19
benazepril hcl 33
benazepril hcl/hydrochlorothiazide 33
BENDEKA 18
BENICAR 33
BENICAR HCT 33
BENLYSTA 54
benzonatate 66
benzoyl peroxide 39
benztropine mesylate 23
BESIVANCE 10
beta carotene 82
betamethasone dipropionate 46
betamethasone valerate 46
betaxolol hcl 34
betaxolol hcl 61
bethanechol chloride 46
bexarotene 22
BEXSERO 55
bicalutamide 18
BICILLIN L-A 9
BICNU 18
BIDIL 37
bimatoprost 59
biocal 82
biosupp 82
biotin 82
biotin 5000 82
biotin/maximum strength 82
biovol 82
bisacodyl ec 41
bisacodyl ec 44
biscolax 41
bismatrol 41
bismatrol maximum strength 42
bisoprolol fumarate 34
bisoprolol fumarate/hydrochlorothiazide 34
BIVIGAM 55
bleomycin sulfate 19
BLEPHAMIDE 10
BLEPHAMIDE S.O.P. 10
Drug Name Page #
blisovi fe 1.5/30 49
blisovi fe 1/20 49
blue gel 39
BOOSTRIX 55
BOSULIF 21
b-plex plus 82
briellyn 49
BRILINTA 32
brimonidine tartrate 61
BRINTELLIX 13
BRIVIACT 11
bromfed dm 66
bromfenac 60
bromocriptine mesylate 23
bromphen/pseudoephedrine
hcl/dextromethorphan hbr
66
BROTAPP 62
BROTAPP DM 66
budesonide 57
budesonide 62
bumetanide 36
BUPHENYL 40
buprenorphine hcl 5
buprenorphine hcl/naloxone hcl 5
buproban 5
bupropion hcl 13
bupropion hcl er 13
bupropion hcl sr 5
bupropion hcl sr 13
bupropion hcl xl 13
buspirone hcl 29
BUSULFEX 18
butalbital/acetaminophen/caffeine 1
butalbital/acetaminophen/caffeine/codeine 3
butalbital/aspirin/caffeine 1
butalbital/aspirin/caffeine/codeine 3
butorphanol tartrate 3
BYDUREON 29
BYDUREON PEN 29
BYETTA 30
BYSTOLIC 34
BYVALSON 34
c 1000 82
c 1000/bioflavonoids/rosehips 82
c 250 82
c 500 82
c 500/rose hips 82
100
Drug Name Page #
c complex 82
c-1000 82
c-1000 prolonged release 82
c-1000/rose hips 83
c-250 83
c-500 83
c-500 prolonged release 83
c-500/rose hips 83
cabergoline 53
CABOMETYX 21
CAFERGOT 17
calcet petites 71
calci-chew 71
calcipotriene 39
calcitonin-salmon 57
calcitrate 71
calcitrene 39
calcitriol 39
calcitriol 57
calcium 72
calcium & magnesium 71
calcium + d3 71
calcium 500 +d3 71
calcium 500/d 71
calcium 500/vitamin d3 71
calcium 600 71
calcium 600 + d 71
calcium 600 with vitamin d 71
calcium 600/vitamin d 71
calcium 600/vitamin d3 71
calcium 600+d 71
calcium 600+d3 71
calcium 600-d 71
calcium acetate 46
calcium antacid 42
calcium antacid extra strength 42
calcium carbonate 71
calcium carbonate/d3 71
calcium carbonate/vitamin d 71
calcium citrate 72
calcium citrate + d 72
calcium citrate + d3 maximum 72
calcium citrate malate/vitamin d 72
calcium citrate maximum/vitamin d 72
calcium citrate w/d 72
calcium citrate/vitamin d 72
calcium citrate/vitamin d3 72
Drug Name Page #
calcium citrate+d 72
calcium gluconate 72
calcium high potency 72
calcium high potency + vitamin d 72
calcium oyster shell 72
calcium/c/d 83
calcium/d 72
calcium/magnesium/zinc 72
calcium/vitamin d 72
calcium+d3 72
cal-gest antacid 42
cal-mag-zinc-d 71
caltrate 600+d 72
caltrate 600+d plus minerals 72
caltrate 600+d3 soft chews 72
calvite p&d 72
camila 52
CANCIDAS 16
candesartan cilexetil 33
candesartan cilexetil/hydrochlorothiazide 33
CAPASTAT SULFATE 18
CAPRELSA 21
captopril 33
captopril/hydrochlorothiazide 33
CARAC 39
CARAFATE 45
CARBAGLU 72
carbamazepine 12
carbamazepine er 12
carbidopa 24
carbidopa/levodopa 23
carbidopa/levodopa er 24
carbidopa/levodopa odt 24
carbidopa/levodopa/entacapone 24
carboplatin 19
carteolol hcl 61
cartia xt 35
carvedilol 34
CAYSTON 65
caziant 49
cefaclor 8
cefaclor er 8
cefadroxil 8
CEFAZOLIN 8
cefazolin sodium 8
CEFAZOLIN SODIUM/DEXTROSE 8
cefdinir 8
101
Drug Name Page #
cefepime 8
cefepime/dextrose 8
cefixime 8
cefotaxime sodium 8
cefotetan 8
cefoxitin sodium 8
cefpodoxime proxetil 8
cefprozil 8
ceftazidime 8
CEFTAZIDIME/DEXTROSE 8
ceftriaxone in iso-osmotic dextrose 8
ceftriaxone sodium 8
cefuroxime axetil 8
cefuroxime sodium 8
celecoxib 1
CELLCEPT INTRAVENOUS 54
CELONTIN 11
centamin 72
centratex 72
centravites 83
centrum 83
centrum adults 83
centrum kids complete 83
centrum silver 83
centrum silver adult 50+ 83
centrum silver ultra womens 83
centrum specialist heart 83
centrum ultra mens 83
cephalexin 8
CEREZYME 40
cerovite advanced formula 83
cerovite jr 83
certa plus 83
certavite senior/antioxidant nutrients 83
certavite/antioxidants 83
CERVARIX 56
cetirizine hcl 62
cetirizine hcl allergy childrens 62
cetirizine hcl childrens allergy 62
cetirizine hcl/pseudoephedrine hcl er 62
CHANTIX 5
CHANTIX CONTINUING MONTH PAK 5
CHANTIX STARTING MONTH PAK 5
chateal 49
CHEMET 70
cheratussin ac 66
cheratussin dac 66
Drug Name Page #
chest congestion relief 66
chest congestion relief pe 66
chewable antacid 42
chewable vitamin c 83
chewable vite childrens 83
chewable vite with iron/childrens 83
childrens allergy 62
childrens aspirin 32
childrens chewable multivitamin 83
childrens chewable vitamin 83
childrens chewable vitamins 83
childrens chewable vitamins/iron 83
childrens ibuprofen 2
childrens loratadine 62
childrens mapap rapid tabs 1
childrens silfedrine 66
childs ibuprofen 2
chlo tuss 66
CHLO TUSS EX 66
chloramphenicol sodium succinate 6
chlorhexidine gluconate 38
chloroquine phosphate 23
chlorothiazide 36
chlorothiazide sodium 36
chlorpromazine hcl 24
chlorthalidone 36
cholestyramine 37
cholestyramine light 37
CHORIONIC GONADOTROPIN 48
ciclodan 16
ciclopirox 16
ciclopirox nail lacquer 16
ciclopirox olamine 16
cidofovir 26
cilostazol 32
CILOXAN 10
cimetidine 43
cimetidine hcl 43
CINRYZE 54
CIPRO HC 10
CIPRODEX 10
ciprofloxacin 10
ciprofloxacin er 10
ciprofloxacin hcl 10
ciprofloxacin i.v.-in d5w 10
cisplatin 19
citalopram hydrobromide 14
102
Drug Name Page #
citracal + d3 maximum 72
citracal maximum 72
citrus calcium +d 84
cladribine 19
claravis 39
clarithromycin 9
clarithromycin er 9
clever choice anti-staticvalved holding
chamber/adult large
58
clever choice anti-staticvalved holding
chamber/medium
58
clever choice anti-staticvalved holding
chamber/small
58
clindacin etz pledgets 6
clindacin-p 6
clindamax 6
clindamycin hcl 6
clindamycin phosphate 6
clindamycin phosphate add-vantage 6
clindamycin phosphate in d5w 6
clindamycin phosphate pharmacy bulk
package
6
CLINIMIX 2.75%/DEXTROSE 5% 72
CLINIMIX 4.25%/DEXTROSE 10% 72
CLINIMIX 4.25%/DEXTROSE 20% 72
CLINIMIX 4.25%/DEXTROSE 25% 72
CLINIMIX 4.25%/DEXTROSE 5% 72
CLINIMIX 5%/DEXTROSE 15% 72
CLINIMIX 5%/DEXTROSE 20% 72
CLINIMIX 5%/DEXTROSE 25% 72
CLINIMIX E 2.75%/DEXTROSE 10% 72
CLINIMIX E 4.25%/DEXTROSE 10% 73
CLINIMIX E 4.25%/DEXTROSE 25% 73
CLINIMIX E 5%/DEXTROSE 25% 73
CLINISOL SF 15% 73
clobetasol propionate 46
clobetasol propionate e 46
clobetasol propionate emollient 46
clodan 46
CLOLAR 19
clomipramine hcl 15
clonazepam 11
clonazepam odt 11
clonidine hcl 32
clonidine hcl er 38
clopidogrel 32
clorazepate dipotassium 29
Drug Name Page #
clotrimazole 16
clotrimazole anti-fungal 16
clotrimazole/betamethasone dipropionate 16
clozapine 26
clozapine odt 26
COARTEM 23
coats aloe creme 39
coats aloe gelly 39
coats aloe liniment 39
coats aloe moisturizing lotion 39
codeine/guaifenesin 66
colchicine 17
COLCRYS 17
cold/cough dm childrens 66
colestipol hcl 37
colistimethate sodium 6
colocort 57
COLY-MYCIN S 61
COMBIGAN 59
COMBIVENT RESPIMAT 64
COMETRIQ 21
compact space chamber/anti-static 58
compact space chamber/anti-static/large
mask
58
compact space chamber/anti-static/medium
mask
58
compact space chamber/anti-static/small
mask
58
companion 84
compete 84
COMPLERA 27
complete 84
complete allergy medicine 62
complex b-100 84
compro 24
COMVAX 56
congestion relief 2
constulose 44
COPAXONE 38
coral calcium 73
COREG CR 34
cormax scalp application 46
cortisone acetate 46
CORTISPORIN-TC 61
corvita 84
corvite 84
corvite 150 84
103
Drug Name Page #
corvite fe 84
corvite free 84
COSMEGEN 19
COTELLIC 21
cough dm 66
cough syrup 66
cranberry urinary comfort 84
CREON 40
CRESTOR 36
CRIXIVAN 28
cromolyn sodium 42
cromolyn sodium 60
cromolyn sodium 65
cryselle-28 49
CUBICIN 7
CUPRIMINE 70
curity gauze pads 2"x2" 39
cvs b complex plus c 84
cvs b-1 84
cvs b-12 84
cvs b-6 84
cvs balanced b-100 84
cvs balanced b-50 84
cvs beta carotene 84
cvs biotin 84
cvs biotin high potency 84
cvs calcium 84
cvs calcium 600 & vitamind3 73
cvs calcium 600 + d/minerals 73
cvs calcium 600+d 73
cvs calcium carbonate 73
cvs calcium chewables 600plus 73
cvs calcium citrate + d 73
cvs calcium citrate +d 73
cvs calcium citrate+d/magnesium 73
cvs calcium/magnesium/zinc 84
cvs childrens chewable complete 84
cvs childrens chewable multivitamin/iron 84
cvs daily energy 84
cvs daily multiple 84
cvs daily multiple for men 84
cvs daily multiple for men 50+ 84
cvs daily multiple for women 84
cvs daily multiple for women 50+ 84
cvs daily multiple plus iron/calcium/zinc 84
cvs e oil 84
cvs electrolyte solution 73
Drug Name Page #
cvs gummy dinos 84
cvs hair skin & nails/an tioxidants 84
cvs iron 73
cvs lancets ultra-thin 30g 58
cvs laxative dietary supplement 44
cvs magnesium 73
cvs oyster shell calcium w/ vit d 73
cvs pediatric electrolyte 73
cvs pediatric electrolyte freezer pops 73
cvs selenium 73
cvs slow release iron 73
cvs spectravite adult 50+ 84
cvs spectravite advanced formula 84
cvs spectravite senior 85
cvs spectravite ultra health mens 85
cvs spectravite ultra mens health 85
cvs spectravite ultra women 85
cvs spectravite ultra womens health 85
cvs spectravite ultra womens health senior 85
cvs super b complex/c 85
cvs vitamin a 85
cvs vitamin b-12 85
cvs vitamin b-12 tr 85
cvs vitamin b-6 85
cvs vitamin c 85
cvs vitamin c/rose hips 85
cvs vitamin e 85
cvs zinc 73
cyclafem 1/35 49
cyclafem 7/7/7 49
cyclobenzaprine hcl 70
cyclophosphamide 18
cycloserine 18
CYCLOSET 30
cyclosporine 54
cyclosporine modified 54
CYRAMZA 22
cyred 49
CYSTADANE 40
CYSTAGON 40
cytarabine 19
cytarabine aqueous 19
dacarbazine 18
daily combo multi vitamin 85
daily multiple vitamin 85
daily multiple vitamin/iron 85
daily multiple vitamins 85
104
Drug Name Page #
daily value multivitamin 85
daily vitamin 85
daily vitamin formula+ir on 85
daily vitamin formula+iron 85
daily vitamin formula+minerals 85
daily vitamins 85
daily vite 85
daily vite with iron 85
daily-vite 85
daily-vite/iron/beta-carotene 85
DALIRESP 65
dallergy 63
danazol 48
dantrolene sodium 26
dapsone 18
DAPTACEL 56
daptomycin 7
DARAPRIM 23
DARZALEX 22
dasetta 1/35 49
dasetta 7/7/7 49
daunorubicin hcl 20
day time multi-symptom cold/flu relief 66
deblitane 52
DECITABINE 20
DECONEX DMX 66
DECONEX IR 66
deep sea nasal spray 66
dekas essential 85
dekas plus 86
DELESTROGEN 49
DELSYM 66
delsym cough + chest congestion dm 66
delsym cough + chest congestion dm
childrens
66
delsym cough + cold daytime 66
delsym cough + cold nighttime 66
delsym cough + cold nighttime childrens 66
delyla 49
DELZICOL 57
demeclocycline hcl 10
DEMSER 35
DENAVIR 29
DEPEN TITRATABS 70
DEPO-ESTRADIOL 49
DEPO-MEDROL 46
DEPO-PROVERA 52
Drug Name Page #
DESCOVY 27
desipramine hcl 15
desloratadine 63
desloratadine odt 63
desmopressin acetate 48
desogestrel/ethinyl estradiol 49
desonide 46
desoximetasone 46
dexamethasone 46
dexamethasone intensol 46
dexamethasone sodium phosphate 46
dexamethasone sodium phosphate 60
DEXILANT 45
dexmethylphenidate hcl 38
dexrazoxane 20
dextroamphetamine sulfate 38
dextroamphetamine sulfate er 38
dextromethorphan polistirex 66
DEXTROSE 10%/NACL 0.45% 73
dextrose 5% /electrolyte #48 viaflex 73
DEXTROSE 10% 73
DEXTROSE 10%/NACL 0.2% 73
DEXTROSE 2.5%/NACL 0.45% 73
DEXTROSE 20% 73
DEXTROSE 25% 73
DEXTROSE 30% 73
DEXTROSE 40% 73
DEXTROSE 5% 73
DEXTROSE 5%/LACTATED RINGERS 73
DEXTROSE 5%/NACL 0.2% 73
DEXTROSE 5%/NACL 0.225% 73
DEXTROSE 5%/NACL 0.3% 73
DEXTROSE 5%/NACL 0.33% 73
DEXTROSE 5%/NACL 0.45% 73
DEXTROSE 5%/NACL 0.9% 73
DEXTROSE 5%/POTASSIUM
CHLORIDE 0.15%
73
DEXTROSE 50% 73
DEXTROSE 70% 73
dialyvite 800 86
dialyvite 800/iron 86
DIAZEPAM 11
diazepam 29
DIBENZYLINE 33
dibucaine 39
diclofenac potassium 2
diclofenac sodium 39
105
Drug Name Page #
diclofenac sodium 60
diclofenac sodium dr 2
diclofenac sodium er 2
dicloxacillin sodium 9
dicyclomine hcl 41
didanosine 27
diflorasone diacetate 46
diflunisal 2
digitek 35
digox 35
digoxin 35
dihydroergotamine mesylate 17
DILANTIN 12
diltiazem cd 35
diltiazem hcl 35
diltiazem hcl cd 35
diltiazem hcl er 35
dilt-xr 35
dimaphen childrens 63
dimaphen dm cold & cough 66
dimaphen dm cold/cough childrens 66
dimenhydrinate 15
dino-life 86
dino-life w extra c 86
dino-life w/iron & zinc 86
diocto 42
diphenhist 63
diphenhydramine hcl 63
diphenoxylate/atropine 42
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
56
disulfiram 5
divalproex sodium 11
divalproex sodium dr 11
divalproex sodium er 11
DOCEFREZ 20
docetaxel 20
docqlace 42
docqlace 44
doc-q-lax 44
docu 42
docusate sodium & senna stimulant
laxative/stool softener
44
docusol kids 42
docusol plus mini-enema 44
dofetilide 34
dok 42
Drug Name Page #
dok 44
dok plus 44
donepezil hcl 13
dorzolamide hcl 61
dorzolamide hcl/timolol maleate 61
doxazosin 45
doxazosin mesylate 45
doxepin hcl 15
doxepin hydrochloride 39
doxercalciferol 57
doxorubicin hcl 20
doxorubicin hcl liposome 20
doxy 100 10
doxycycline 10
doxycycline hyclate 10
doxycycline monohydrate 10
DR SMITHS DIAPER 39
dr smiths diaper rash spray 39
dr smiths rash + skin 39
DRISDOL 86
dronabinol 15
DROXIA 19
DULERA 62
duloxetine hcl 14
duofer 74
DURAFLU 66
DURAMORPH 3
DUREZOL 60
dutasteride 45
dutasteride/tamsulosin hydrochloride 45
e.e.s. 400 9
E.E.S. GRANULES 9
e-400 86
e400 mixed 86
ear drops earwax removal aid 61
earwax treatment drops 61
easy mini eject lancing device 58
ecee plus 86
econazole nitrate 16
econtra ez 52
ed a-hist 63
ed a-hist dm 66
ed a-hist pse 63
ed bron gp 66
ed chlorped 63
ed chlorped d 63
ed chlorped jr 63
106
Drug Name Page #
ed-apap 1
ed-chlortan 63
EDECRIN 36
ed-spaz 41
EDURANT 27
effervescent pain relief 2
EFFIENT 32
ELAPRASE 40
ELIDEL 39
ELIGARD 53
elinest 49
ELIQUIS 31
ELITEK 19
ELLA 52
ELMIRON 46
EMCYT 19
EMEND 15
emoquette 49
EMPLICITI 22
EMSAM 13
EMTRIVA 27
enalapril maleate 33
enalapril maleate/hydrochlorothiazide 33
ENBREL 54
ENBREL SURECLICK 54
endacof-dm 66
endocet 3
enema ready-to-use 44
enemeez mini 42
enemeez plus 42
enfamil enfalyte 58
ENGERIX-B 56
enlyte 74
enoxaparin sodium 31
enpresse-28 49
enskyce 49
entacapone 23
entecavir 26
enteric coated aspirin 2
ENTRESTO 33
enulose 44
ENVARSUS XR 54
e-oil 86
epinastine hcl 60
epinephrine hcl 64
EPIPEN 2-PAK 64
EPIPEN-JR 2-PAK 64
Drug Name Page #
epirubicin hcl 20
epitol 12
EPIVIR HBV 26
EPZICOM 28
eql one daily essential 86
eql pediatric electrolyte 74
ERBITUX 22
ergocalciferol 86
ergoloid mesylates 12
ERIVEDGE 21
errin 52
ERWINAZE 20
ery 9
ERYPED 200 9
ERYPED 400 9
ERY-TAB 9
ERYTHROCIN LACTOBIONATE 9
erythrocin stearate 9
erythromycin 9
erythromycin base 9
erythromycin ethylsuccinate 9
erythromycin/benzoyl peroxide 39
ESBRIET 66
escitalopram oxalate 14
esgic 1
esomeprazole magnesium 45
esomeprazole sodium 45
essentia 86
essential balance 86
estarylla 49
estradiol 49
estradiol valerate 49
estradiol/norethindrone acetate 49
ESTRING 49
ethacrynate sodium 36
ethacrynic acid 36
ethambutol hcl 18
ethosuximide 11
etidronate disodium 57
etodolac 2
etodolac er 2
ETOPOPHOS 21
etoposide 21
EVOMELA 18
EVOTAZ 28
EXELON 13
exemestane 21
107
Drug Name Page #
EXJADE 70
extra action cough 66
eye drops 60
ezfe 200 74
FABRAZYME 40
fallback solo 52
falmina 49
famciclovir 29
famotidine 43
famotidine premixed 43
FANAPT 25
FANAPT TITRATION PACK 25
FARESTON 19
FARYDAK 21
FASLODEX 19
FAZACLO 26
fe c 74
fe c tab 74
felbamate 12
felodipine er 35
FEMRING 49
fenofibrate 36
fenofibrate micronized 36
fenofibric acid dr 36
fenoprofen calcium 2
fentanyl 3
fentanyl citrate 3
fentanyl citrate oral transmucosal 3
feosol 74
feosol bifera 74
ferate 74
fergon 74
fer-in-sol 74
fer-iron 74
feriva 21/7 74
ferivafa 74
ferosul 74
ferralet 90 74
ferraplus 90 74
ferretts 74
ferretts ips 74
ferrex 150 74
ferrex 150 forte 74
ferric x-150 74
ferrimin 150 74
FERRIPROX 58
ferrocite 74
Drug Name Page #
ferrous drops 74
ferrous fumarate 324 74
ferrous gluconate 74
ferrous sulfate 74
ferrousul 74
FETZIMA 14
FETZIMA TITRATION PACK 14
fexofenadine hcl 63
fexofenadine hcl childrens allergy 63
fiber laxative 44
fiber tabs 42
fiber-lax 42
fifty50 unilet lancets 33g 58
finasteride 45
FIRAZYR 54
FIRMAGON 53
flavoxate hcl 45
FLEBOGAMMA DIF 55
flecainide acetate 34
FLEET PEDIATRIC 42
flintstones complete 86
flintstones plus extra c 86
flintstones/my first 86
FLOVENT DISKUS 62
FLOVENT HFA 62
FLOWTUSS 66
fluconazole 16
fluconazole in dextrose 16
fluconazole in nacl 16
flucytosine 16
fludarabine phosphate 20
fludrocortisone acetate 46
flunisolide 62
fluocinolone acetonide 46
fluocinolone acetonide 61
fluocinolone acetonide body 46
fluocinolone acetonide ear drops 46
fluocinolone acetonide scalp 46
fluocinonide 47
fluocinonide-e 47
fluoride 74
fluoritab 74
fluorometholone 60
fluorouracil 19
fluorouracil 39
fluoxetine 14
fluoxetine dr 14
108
Drug Name Page #
fluoxetine hcl 14
fluphenazine decanoate 24
fluphenazine hcl 24
flurbiprofen 2
flurbiprofen sodium 60
flutamide 18
fluticasone propionate 47
fluticasone propionate 62
fluvastatin 36
fluvoxamine maleate 14
fluvoxamine maleate er 14
focalgin dss 74
folic acid 86
folitab 500 86
FOLOTYN 19
foltabs 800 86
fomepizole 58
fondaparinux sodium 31
fora d40/g31 blood glucose test strips 58
fora lancets 58
fora lancing device/clearcap 58
fora tn'g/tn'g voice blood glucose test strips 58
FORADIL AEROLIZER 65
formula em 15
fortavit 86
FORTEO 57
fosfree 86
fosinopril sodium 33
fosinopril sodium/hydrochlorothiazide 33
fosphenytoin sodium 12
FREAMINE HBC 6.9% 74
FREAMINE III 74
freestyle precision neo blood glucose test
strips
58
FRESHKOTE 60
fruit c 500 86
fruity c 86
fruity chewables multivitamin 86
full spectrum b/vitamin c 86
FUNGOID TINCTURE 16
furosemide 36
FUSILEV 20
fusion 74
fusion plus 75
FUZEON 28
FYCOMPA 11
gabapentin 11
Drug Name Page #
GABITRIL 11
galantamine hydrobromide 13
GAMASTAN S/D 55
GAMMAGARD LIQUID 55
GAMMAKED 55
GAMMAPLEX 55
GAMUNEX-C 55
ganciclovir 26
GARDASIL 56
GARDASIL 9 56
gas relief 42
gas relief extra strength 42
gas relief maximum strength 42
GATTEX 42
gavilyte-c 44
gavilyte-g 44
gavilyte-n/flavor pack 44
GAZYVA 22
gemcitabine 19
gemcitabine hcl 19
gemfibrozil 36
generlac 44
gengraf 54
gentak 6
gentamicin sulfate 6
gentamicin sulfate pediatric 6
gentamicin sulfate/0.9% sodium chloride 6
GENVOYA 27
GEODON 25
gildagia 49
gildess 1.5/30 49
gildess 1/20 50
gildess fe 1.5/30 50
gildess fe 1/20 50
GILOTRIF 21
glatopa 38
GLEEVEC 21
GLEOSTINE 18
glimepiride 30
glipizide 30
glipizide er 30
glipizide xl 30
glipizide/metformin hcl 30
GLUCAGEN HYPOKIT 30
glucose meter test strips advanced 58
glycopyrrolate 41
glydo 5
109
Drug Name Page #
GLYSET 30
gnp all day allergy 63
gnp allergy 63
gnp animal shapes 86
gnp animal shapes plus extra c 86
gnp animal shapes plus iron 86
gnp antacid anti-gas 42
gnp arthritis pain relief 1
gnp b-50 balanced 86
gnp calcium 75
gnp calcium 1200 75
gnp calcium 500 +d3 75
gnp calcium 500/d 75
gnp calcium 600/d 75
gnp calcium citrate +d3 75
gnp calcium citrate+d maximum 75
gnp calcium/magnesium/zinc 75
gnp calcuim/vitamin d/minerals 75
gnp century 87
gnp century adults 50+ senior 87
gnp century cardio healthformula 87
gnp century ultimate mens complete 87
gnp century ultimate womens complete 87
gnp century ultimate womens senior formula 87
gnp childrens chewables/extra c 87
gnp childrens chewables/iron 87
gnp dayhist allergy 63
gnp easy touch glucose test strips 58
gnp enema 44
gnp essential one daily 87
gnp hair/skin/nails 87
gnp ibuprofen 2
gnp ibuprofen junior strength 2
gnp iron 75
gnp little ones childrens 87
gnp loratadine 63
gnp magnesium 75
gnp masanti maximum strength 42
gnp masanti regular strength 42
gnp mega multi for men 87
gnp mega multi for women 87
gnp niacin tr 75
gnp omeprazole 45
gnp one daily maximum 87
gnp one daily mens health 50+ 87
gnp one daily plus iron 87
gnp one daily womens health 50+ 87
Drug Name Page #
gnp opti-vitamins 87
gnp pediatric electrolyte 75
gnp therapeutic-m 75
gnp tussin 66
gnp tussin dm 66
gnp vitamin a 87
gnp vitamin b-12 75
gnp vitamin b-12 tr 75
gnp vitamin b-6 75
gnp vitamin c 75
gnp vitamin c 87
gnp vitamin c drops 75
gnp vitamin c tr 87
gnp vitamin c w/rose hips 87
gnp vitamin c w/rose hips tr 87
gnp vitamin e 75
gnp zinc 75
gnp zoochews gummies 87
granisetron hcl 15
granisetron hcl 15
griseofulvin microsize 16
griseofulvin ultramicrosize 16
guaiatussin ac 67
guaifenesin ac 67
guaifenesin and pseudoephedrine
hydrochloride
67
guaifenesin er 67
guaifenesin/codeine 67
GUANIDINE HCL 17
HALAVEN 20
halls defense vitamin c drops 88
halobetasol propionate 47
haloperidol 24
haloperidol decanoate 24
haloperidol lactate 24
hard nails 88
HARVONI 26
HAVRIX 56
heartburn treatment 24 hour 45
heather 52
h-e-b incontrol lancets micro thin 33g 58
h-e-b oral electrolyte solution 75
hecoria 54
hemocyte 75
hemocyte plus 75
hemocyte-f 75
hemorrhoidal 39
110
Drug Name Page #
heparin sodium 31
heparin sodium/d5w 31
heparin sodium/nacl 0.45% 31
heparin sodium/nacl 0.9% 31
heparin sodium/sodium chloride 0.9% 31
heparin sodium/sodium chloride 0.9%
premix
31
HEPATAMINE 75
HERCEPTIN 22
HETLIOZ 38
HEXALEN 18
HIBERIX 56
histaflex 1
histex 63
histex pd 63
histex-dm 67
histex-pe 67
hm pediatric electrolyte 75
honey bears 88
honey bears w/iron and zinc 88
HUMALOG 31
HUMALOG KWIKPEN 30
HUMALOG MIX 50/50 30
HUMALOG MIX 50/50 KWIKPEN 30
HUMALOG MIX 75/25 30
HUMALOG MIX 75/25 KWIKPEN 31
HUMIRA 54
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK
54
HUMIRA PEN 54
HUMIRA PEN-CROHNS
DISEASESTARTER
54
HUMIRA PEN-PSORIASIS STARTER 54
HUMULIN 70/30 31
HUMULIN 70/30 KWIKPEN 31
HUMULIN N 31
HUMULIN N KWIKPEN 31
HUMULIN R 31
HUMULIN R U-500 (CONCENTRATED) 31
HUMULIN R U-500 KWIKPEN 31
HYCOFENIX 67
hydralazine hcl 37
hydro skin maximum strength 47
hydrochlorothiazide 36
hydrocodone bitartrate/acetaminophen 3
hydrocodone bitartrate/chlorpheniramine
maleate/pse
67
Drug Name Page #
hydrocodone bitartrate/homatropine
methylbromide
67
hydrocodone polistirex/chlorpheniramine
polistirex
67
hydrocodone/acetaminophen 4
hydrocodone/homatropine 67
hydrocodone/ibuprofen 4
hydrocortisone 47
hydrocortisone 57
hydrocortisone butyrate 47
hydrocortisone butyrate (lipid) 47
hydrocortisone butyrate (lipophilic) 47
hydrocortisone in absorbase 47
hydrocortisone valerate 47
hydrocortisone/acetic acid 61
hydrocortisone/aloe 47
hydromet 67
hydromorphone hcl 4
hydromorphone hcl dosette 4
hydroskin 47
hydroxychloroquine sulfate 23
hydroxyprogesterone caproate 52
hydroxyurea 19
hyoscyamine sulfate 41
hyoscyamine sulfate odt 41
hyosyne 41
i.l.x. b-12 75
ibandronate sodium 57
IBRANCE 21
ibu-200 2
ibudone 4
ibu-drops 2
ibu-drops infants 2
ibuprofen 2
ibuprofen childrens 2
ibuprofen junior strength 2
icaps areds formula 88
icaps mv 88
icaps plus 88
icar pediatric 75
icar-c 75
ICLUSIG 21
idarubicin hcl 20
iferex 150 75
ifosfamide 18
ILARIS 55
ILEVRO 60
111
Drug Name Page #
ilotycin 10
imatinib mesylate 21
IMBRUVICA 21
imipenem/cilastatin 8
imipramine hcl 15
imipramine pamoate 15
imiquimod 39
IMOVAX RABIES (H.D.C.V.) 56
INCRELEX 48
indapamide 36
INFANRIX 56
infants gas relief 42
infants ibuprofen 2
infants simethicone 42
infed 75
infumorph 200 3
infumorph 500 3
INLYTA 21
inspirachamber/large 58
integra 88
integra f 88
integra plus 88
INTELENCE 27
INTRALIPID 58
INTRALIPID 81
INTRON A 26
INTRON A W/DILUENT 26
introvale 50
INVANZ 8
INVEGA 25
INVEGA SUSTENNA 25
INVEGA TRINZA 25
INVIRASE 28
INVOKAMET 30
INVOKAMET XR 30
INVOKANA 30
iophen c-nr 67
iophen dm-nr 67
iophen-nr 67
iosat 67
IPOL INACTIVATED IPV 56
ipratropium bromide 64
ipratropium bromide/albuterol sulfate 64
irbesartan 33
irbesartan/hydrochlorothiazide 33
IRESSA 21
irinotecan 20
Drug Name Page #
iron 75
iron 88
iron 100/c 88
iron supplement childrens 88
irospan 24/6 75
ISENTRESS 27
isoniazid 18
ISOPTO TEARS 60
isosorbide dinitrate 37
isosorbide dinitrate er 37
isosorbide mononitrate 37
isosorbide mononitrate er 37
isotonic gentamicin 6
isradipine 35
ISTODAX 20
itraconazole 16
ivermectin 23
IXEMPRA KIT 20
IXIARO 56
JADENU 70
JAKAFI 21
JALYN 45
jantoven 31
JANUMET 30
JANUMET XR 30
JANUVIA 30
jencycla 52
JENTADUETO 30
JENTADUETO XR 30
JEVTANA 20
J-MAX 67
J-TAN D PD 63
J-TAN PD 63
juleber 50
junel 1.5/30 50
junel 1/20 50
junel fe 1.5/30 50
junel fe 1/20 50
junior mapap 1
KABIVEN 75
KADCYLA 22
KALETRA 28
KALYDECO 65
kao-tin 42
kao-tin 44
kariva 50
KCL 0.075%/D5W/NACL 0.45% 75
112
Drug Name Page #
kcl 0.15%/d5w/ nacl 0.3% 75
KCL 0.15%/D5W/LR 75
KCL 0.15%/D5W/NACL 0.2% 76
kcl 0.15%/d5w/nacl 0.225% 76
kcl 0.15%/d5w/nacl 0.45% 76
KCL 0.15%/D5W/NACL 0.9% 76
KCL 0.3%/D5W/LR IV LAC RING 76
KCL 0.3%/D5W/NACL 0.45% 76
kcl 0.3%/d5w/nacl 0.9% 76
kelnor 1/35 50
KETEK 10
ketoconazole 16
ketoprofen 2
ketoprofen er 2
ketorolac tromethamine 60
KEYTRUDA 22
kidkare cough/cold 67
kimidess 50
KINERET 54
KINRIX 56
kionex 70
klor-con 76
klor-con 10 76
klor-con 8 76
klor-con m10 76
klor-con m20 76
klor-con sprinkle 76
kobee 88
KORLYM 48
kp adults 50+ daily formula 88
kp adults daily formula 88
kp b complex/c 88
kp ferrous gluconate 76
kp ferrous sulfate 76
kp mens 50+ daily formula 88
kp mens daily formula 88
kp vitamin e 88
kp womens 50+ daily formula 88
kp womens daily formula 88
k-sol 75
kurvelo 50
KUVAN 40
KYNAMRO 37
labetalol hcl 34
LACRISERT 60
LACTATED RINGERS 76
LACTATED RINGERS IRRIGATION 58
Drug Name Page #
LACTATED RINGERS VIAFLEX 76
lactulose 44
lamivudine 26
lamivudine 28
lamivudine/zidovudine 28
lamotrigine 12
lamotrigine er 12
lamotrigine odt 12
LANOXIN PEDIATRIC 35
lansoprazole 45
lansoprazole/amoxicillin/clarithromycin 7
LANTUS 31
LANTUS SOLOSTAR 31
larin 1.5/30 50
larin 1/20 50
larin fe 1.5/30 50
larin fe 1/20 50
larissia 50
latanoprost 59
LATUDA 25
laxative 42
LAZANDA 4
leflunomide 55
LENVIMA 10 MG DAILY DOSE 21
LENVIMA 14 MG DAILY DOSE 21
LENVIMA 18 MG DAILY DOSE 21
LENVIMA 20 MG DAILY DOSE 22
LENVIMA 24 MG DAILY DOSE 22
LENVIMA 8 MG DAILY DOSE 22
lessina 50
LETAIRIS 65
letrozole 21
leucovorin calcium 20
LEUKERAN 18
LEUKINE 32
leuprolide acetate 53
LEVEMIR 31
LEVEMIR FLEXTOUCH 31
levetiracetam 11
levetiracetam er 11
levobunolol hcl 61
levocarnitine 58
levocetirizine dihydrochloride 63
levofloxacin 10
levofloxacin in d5w 10
levoleucovorin 20
levoleucovorin calcium 20
113
Drug Name Page #
levonest 50
levonorgestrel and ethinyl estradiol 50
levonorgestrel/ethinyl estradiol 50
levora 0.15/30-28 50
levorphanol tartrate 3
levothyroxine sodium 52
LEVOXYL 52
LEXIVA 28
lidocaine 5
lidocaine 39
lidocaine hcl 5
lidocaine hcl 34
lidocaine hcl jelly 5
lidocaine hcl viscous 5
lidocaine viscous 5
lidocaine/prilocaine 5
life pack mens 88
life pack womens 88
LINCOCIN 7
lincomycin hcl 7
lindane 23
linezolid 7
LINZESS 44
liothyronine sodium 52
LIPOFEN 36
liquid calcium/vitamin d 76
liquitears 60
lisinopril 33
lisinopril/hydrochlorothiazide 33
lithium carbonate 29
lithium carbonate er 29
l-methyl-b6-b12 88
LODRANE D 63
lohist-d 63
lohist-dm 67
LOMUSTINE 18
LONSURF 19
loperamide hcl 42
lopreeza 50
loratadine 63
loratadine childrens 63
loratadine hives relief 63
loratadine-d 12hr 63
loratadine-d 24hr 63
lorazepam 29
lorazepam intensol 29
lorcet 4
Drug Name Page #
lorcet hd 4
lorcet plus 4
lortab 4
lortuss dm 67
lortuss ex 67
lortuss lq 67
losartan potassium 33
losartan potassium/hydrochlorothiazide 33
LOTEMAX 61
lovastatin 36
low-ogestrel 50
loxapine 24
loxapine succinate 24
lubricating plus eye drops 60
lubrifresh p.m. 60
ludent 76
LUMIGAN 59
LUMIZYME 40
LUPRON DEPOT 53
LUPRON DEPOT-PED 53
lutera 50
LYNPARZA 22
LYRICA 11
lysiplex plus 88
LYSODREN 53
lyza 52
magnesium 42
magnesium 76
magnesium 27 76
magnesium elemental 76
magnesium oxide 42
magnesium sulfate 76
magnesium sulfate in d5w 76
mag-tab sr 76
major-prep hemorrhoidal 39
MAKENA 52
malathion 23
mapap 1
mapap acetaminophen extrastrength 1
mapap arthritis pain 1
mapap childrens 1
mapap cold formula multi-symptom 67
mapap pm 1
mapap sinus maximum strength congestion
and pain
67
maprotiline hcl 13
margesic 1
114
Drug Name Page #
marlissa 50
MARPLAN 13
mask vortex/child/frog 58
mask vortex/toddler/lady bug 58
MATULANE 18
matzim la 35
meclizine hcl 15
meclofenamate sodium 2
medicated body powder 39
MEDROL 47
medroxyprogesterone acetate 52
mefloquine hcl 23
mega multiple w/chelated minerals 88
mega multivitamin for men 88
mega multivitamin for women 88
megestrol acetate 52
MEKINIST 22
meloxicam 2
melphalan hydrochloride 18
memantine hcl 13
memantine hcl titration pak 13
memantine hydrochloride 13
MENACTRA 56
M-END DMX 67
M-END MAX D 67
MENEST 50
MENHIBRIX 56
MENOMUNE-A/C/Y/W-135 56
MENOSTAR 50
MENVEO 56
MEPHYTON 88
mercaptopurine 19
meribin 88
meropenem 8
meropenem/sodium chloride 8
mesalamine 57
mesna 20
MESNEX 20
MESTINON TIMESPAN 17
metadate er 38
metaproterenol sulfate 65
metformin hcl 30
metformin hcl er 30
METHADONE HCL 3
methadone hcl intensol 3
methazolamide 61
methenamine hippurate 7
Drug Name Page #
methimazole 54
methotrexate 55
methotrexate sodium 55
methoxsalen 39
methscopolamine bromide 41
methylphenidate hcl 38
methylphenidate hcl er 38
methylphenidate hcl sr 38
methylprednisolone 47
methylprednisolone acetate 47
methylprednisolone dose pack 47
methylprednisolone sodiumsuccinate 47
metipranolol 61
metoclopramide hcl 42
metolazone 36
metoprolol succinate er 34
metoprolol tartrate 34
metoprolol/hydrochlorothiazide 34
metronidazole 7
metronidazole in nacl 0.79% 7
metronidazole vaginal 7
mexiletine hcl 34
MIACALCIN 57
mi-acid 42
mi-acid gas relief 42
mi-acid maximum strength 42
miconazole 16
miconazole 7 16
miconazole nitrate 16
microgestin 1.5/30 50
microgestin 1/20 50
microgestin fe 50
microgestin fe 1.5/30 50
midodrine hcl 32
MIGERGOT 17
miglitol 30
migraine formula 2
milk of magnesia 42
milk of magnesia 44
milk of magnesia concentrate 42
mimvey 50
mimvey lo 50
minitran 37
MINIVELLE 50
minocycline hcl 10
minoxidil 37
mintox maximum strength 43
115
Drug Name Page #
mirtazapine 13
mirtazapine odt 13
misoprostol 45
mitomycin 20
mitoxantrone hcl 20
M-M-R II 56
modafinil 70
moderiba 26
moderiba 1200 dose pack 26
moderiba 800 dose pack 26
moexipril hcl 33
moexipril/hydrochlorothiazide 33
molindone hydrochloride 26
mometasone furoate 47
mondoxyne nl 10
monocal 76
mono-linyah 50
montelukast sodium 64
morgidox 1x100mg 10
morgidox 1x50mg 10
morgidox 2x100mg 10
morphine sulfate 3
morphine sulfate 4
morphine sulfate add-vantage 4
morphine sulfate er 3
MOVIPREP 44
MOXEZA 10
moxifloxacin hcl 10
MOZOBIL 76
mtx support 88
mucaphed 67
MUCINEX 68
mucinex chest congestion childrens 67
mucinex childrens cold cough & sore throat 67
mucinex childrens multi-symptom cold 67
MUCINEX CHILDRENS
MULTI-SYMPTOM COLD & FEVER
67
mucinex congestion & cough childrens 67
mucinex cough childrens 67
MUCINEX COUGH FOR KIDS 67
MUCINEX D 67
MUCINEX D MAXIMUM STRENGTH 67
MUCINEX DM 67
MUCINEX DM MAXIMUM STRENGTH 68
mucinex fast-max cold & sinus 68
MUCINEX FAST-MAX COLD FLU&
SORE THROAT
68
Drug Name Page #
mucinex fast-max day time/night time 68
mucinex fast-max day/night maximum
strength
68
mucinex fast-max dm max 68
mucinex fast-max night time cold & flu 68
mucinex fast-max severe cold 68
mucinex fast-max severe congestion &
cough
68
MUCINEX FOR KIDS 68
mucinex maximum strength 68
mucinex multi-symptom cold day/night pack 68
mucinex multi-symptom cold night time
childrens
68
mucinex sinus-max day/night 68
mucinex sinus-max full force 68
mucinex sinus-max moisture smart 68
mucinex sinus-max pressure & pain 68
mucinex sinus-max severe congestion relief 68
mucinex stuffy nose & cold childrens 68
mucus relief 68
mucus-er 68
mucusrelief sinus 68
MULTAQ 34
multi complete/iron 88
multi vitamin daily 88
multi-day plus iron 88
multi-day vitamins 88
multi-delyn 88
multi-delyn/iron 88
multi-lancet device 2 58
multilex 89
multilex-t&m 89
multiple vitamin/minerals/no iron 89
multiple vitamins 89
multiple vitamins plain 89
multiple vitamins/iron 89
multi-vitamin 89
multivitamin & mineral 89
multi-vitamin daily 88
multi-vitamin hp/minerals 88
multi-vitamin/minerals 88
multi-vitamins 88
mupirocin 7
mupirocin calcium 7
MURO 128 60
MUSTARGEN 18
my way 52
116
Drug Name Page #
mycophenolate mofetil 55
mycophenolic acid dr 55
mydral 60
myferon 150 76
mykidz iron 89
mykidz iron 10 89
myorisan 39
mytab gas 43
mytab gas max str 43
my-vitalife 89
myzilra 50
nabumetone 2
nadolol 34
nadolol/bendroflumethiazide 34
nafcillin sodium 9
naftifine hcl 16
naftifine hydrochloride 16
NAFTIN 16
NAGLAZYME 40
nalbuphine hcl 4
naloxone hcl 5
naltrexone hcl 5
NAMENDA 13
NAMENDA TITRATION PAK 13
NAMENDA XR 13
NAMENDA XR TITRATION PACK 13
NAMZARIC 12
naphazoline hcl 60
naproxen 2
naproxen dr 2
naproxen sodium 2
naratriptan hcl 17
NARCAN 5
nasal decongestant 68
nasal decongestant pe 68
nasal decongestant spray 68
NASOPEN PE 63
NATACYN 16
natalvirt flt 76
nateglinide 30
NATPARA 58
natural balance tears 60
natural fiber therapy 43
natures tears 60
NEBUPENT 23
necon 0.5/35-28 51
necon 1/35 51
Drug Name Page #
necon 1/50-28 51
necon 10/11-28 51
necon 7/7/7 51
nefazodone hcl 13
neomycin sulfate 6
neomycin/bacitracin/polymyxin 7
neomycin/polymyxin b sulfates 6
neomycin/polymyxin/bacitracin zinc 7
neomycin/polymyxin/bacitracin/hydrocortis
one
7
neomycin/polymyxin/dexamethasone 61
neomycin/polymyxin/gramicidin 7
neomycin/polymyxin/hc 61
neomycin/polymyxin/hydrocortisone 7
neomycin/polymyxin/hydrocortisone 61
neo-polycin 7
neo-polycin hc 7
NEPHRAMINE 76
nephrocaps 89
nephron fa 76
nephronex 89
nephro-vite 89
NEULASTA 32
NEUMEGA 32
NEUPOGEN 32
NEUPRO 23
nevirapine 27
nevirapine er 27
NEXAVAR 22
next choice one dose 52
niacin 37
niacin 89
niacin er 37
niacin er 89
niacin sr 89
niacin tr 89
niacor 37
nicardipine hcl 35
NICODERM CQ 5
nicorelief 5
NICORETTE 5
NICORETTE MINI 5
NICORETTE STARTER KIT 5
nicotine polacrilex 5
nicotine transdermal system 5
nicotine transdermal system step 1 5
nicotine transdermal system step 2 5
117
Drug Name Page #
nicotine transdermal system step 3 6
NICOTROL INHALER 6
NICOTROL NS 6
nifedical xl 35
nifedipine er 35
night time multi-symptom cold/flu relief 68
night time sleep aid 63
NILANDRON 18
nilutamide 18
nimodipine 35
ninjacof 68
ninjacof-a 68
ninjacof-xg 68
NINLARO 20
NIPENT 19
nisoldipine 35
nisoldipine er 35
nitrofurantoin 7
nitrofurantoin macrocrystals 7
nitrofurantoin monohydrate 7
nitrofurantoin monohydrate/macrocrystals 7
nitroglycerin 37
nitroglycerin lingual 37
nitroglycerin transdermal 37
NITROSTAT 37
nizatidine 43
no iron multiple vitamin/minerals 89
nohist-dm 68
nohist-lq 63
norethindrone 52
norethindrone acetate 52
norethindrone acetate/ethinyl estradiol 51
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
51
norgestimate/ethinyl estradiol 51
NORITATE 7
norlyroc 52
NORMOSOL -R 76
NORMOSOL-M IN D5W 76
NORMOSOL-R 76
NORMOSOL-R IN D5W 76
NORTHERA 35
nortrel 0.5/35 (28) 51
nortrel 1/35 51
nortrel 7/7/7 51
nortriptyline hcl 15
NORVIR 28
Drug Name Page #
NOVAFERRUM 125 76
NOVAFERRUM 50 76
NOVAFERRUM PEDIATRIC DROPS 76
NOVAREL 48
novofine 30gx8mm 58
novofine 31 58
novofine 32gx6mm 58
novofine autocover 30gx8mm 58
novotwist 30gx8mm 58
novotwist 32gx5mm 59
NOXAFIL 16
nrs nasal relief 68
NUEDEXTA 38
nu-iron 150 76
nulev 41
NULOJIX 55
nu-mag 76
NUPLAZID 25
nutricap 89
NUTRILIPID 81
NUTRILYTE 77
NUTRILYTE II 76
nutrivit 89
NUVIGIL 70
nyamyc 16
nystatin 16
nystatin/triamcinolone 16
nystop 17
oceanic selenium 77
OCTAGAM 55
octreotide acetate 53
ODEFSEY 27
ODOMZO 20
ofloxacin 10
ogestrel 51
olanzapine 25
olanzapine odt 25
olanzapine/fluoxetine 14
olopatadine hcl 60
OLYSIO 26
omega-3-acid ethyl esters 37
omeprazole 45
omeprazole magnesium 45
omnicap 89
ONCASPAR 20
once daily 89
once daily/iron 89
118
Drug Name Page #
oncovite 89
ondansetron hcl 15
ondansetron odt 15
one daily 90
one daily complete 89
one daily maximum 89
one daily mens 89
one daily plus iron 89
one daily plus minerals 89
one daily womens 50+ 89
one daily/iron/calcium 89
one daily/minerals 89
one-a-day essential 90
one-a-day mens 50+ advantage 90
one-a-day teen advantage for her 90
one-a-day teen advantage for him 90
one-a-day womens formula 90
one-daily multi vitamins 90
one-way valved
expiratorymouthpiece/disposable
59
one-way valved inspiratory
mouthpiece/disposable
59
ONFI 11
opcicon one-step 52
OPDIVO 22
OPSUMIT 65
opti-clear 60
oralone 38
oralyte 77
oralyte freezer pops 77
ORAP 24
orazinc 77
ORFADIN 41
organ-i nr 68
orphenadrine citrate er 70
orsythia 51
os-cal 77
os-cal calcium + d3 77
os-cal extra d3 77
os-cal ultra 77
oscimin 41
OSMOPREP 43
osteo-poretical 77
oxacillin sodium 9
oxaliplatin 20
oxandrolone 48
oxaprozin 2
Drug Name Page #
oxazepam 29
oxcarbazepine 12
oxybutynin chloride 45
oxybutynin chloride er 45
oxycodone hcl 4
oxycodone/acetaminophen 4
oxycodone/aspirin 4
oxycodone/ibuprofen 4
oxymorphone hydrochloride er 3
oysco 500 77
oysco 500+d 77
oysco d 77
oyst-cal-d 500 77
oyster calcium 77
oyster shell calcium 77
oyster shell calcium + d 77
oyster shell calcium + d3 77
oyster shell calcium + vitamin d 77
oyster shell calcium 250+d 77
oyster shell calcium 500 77
oyster shell calcium 500 + d 77
oyster shell calcium 500/d 77
oyster shell calcium 500+d 77
oyster shell calcium plusvitamin d 77
oyster shell calcium/d 77
oyster shell calcium/d3 77
oyster shell calcium/vitamin d 77
oyster shell calcium+d 77
oystercal-d 77
pa b-complex with b-12 90
pa biotin 90
pa oyster shell calcium 90
pa vitamin b-12 tr 90
pa vitamin e 90
pacerone 34
paclitaxel 20
pain & fever 1
pain & fever childrens 1
pain & fever extra strength 1
pain relief sinus pe daytime 68
pain reliever pm extra strength 1
paliperidone er 25
pamidronate disodium 57
PANCRELIPASE 41
panda mask large 59
panda mask medium 59
panda mask small 59
119
Drug Name Page #
PANRETIN 22
pantoprazole sodium 45
pantothenic acid 59
paricalcitol 57
paroex 38
paromomycin sulfate 6
paroxetine hcl 14
paroxetine hcl er 14
PASER 18
PATADAY 60
PAXIL 14
PAZEO 60
pedialyte 77
pedialyte advanced care 77
pedialyte freezer pops 77
pedialyte singles 77
pediatric cough/cold 68
pediatric electrolyte 78
pediatric electrolyte freeze pops 78
pediatric electrolyte freezer pops 78
pediatric electrolyte/zinc 78
pediatric medium mask 59
pediatric mouthpiece/disposable 59
pediatric panda mask 59
pediatric small mask 59
PEDVAX HIB 56
peg 3350 44
peg 3350/electrolytes 44
peg3350 44
peg-3350/electrolytes 44
peg-3350/nacl/na bicarbonate/kcl 44
PEGANONE 12
PEGINTRON 27
PEG-INTRON REDIPEN 26
PEG-INTRON REDIPEN PAK 4 26
penicillin g potassium 9
penicillin v potassium 9
PENTAM 300 23
pentoxifylline er 35
peptic relief 43
PERFOROMIST 65
peridin-c 90
PERIKABIVEN 78
perindopril erbumine 33
periogard 38
PERJETA 22
permethrin 23
Drug Name Page #
perphenazine 24
perphenazine/amitriptyline 15
PFIZERPEN-G 9
pharmacist choice no coding blood glucose
test strips
59
pharmacist choice ultra thin lancets 33g 59
phenazopyridine hcl 46
phenelzine sulfate 14
phenobarbital 11
phenoxybenzamine hydrochloride 33
phenylephrine hcl/pyrilamine maleate 68
phenylhistine dh 69
phenytoin 12
phenytoin infatabs 12
phenytoin sodium 12
phenytoin sodium extended 12
philith 51
phillips 43
PHOSLYRA 46
phospha 250 neutral 78
PHOSPHOLINE IODIDE 61
PHYSIOLYTE 59
PHYSIOSOL IRRIGATION 59
PICATO 39
pilocarpine hcl 38
pilocarpine hcl 61
pilocarpine hydrochloride 38
pimozide 24
pimtrea 51
pindolol 34
pink bismuth 43
pioglitazone hcl 30
pioglitazone hcl/metformin hcl 30
pioglitazone hcl-glimepiride 30
piperacillin sodium/ tazobactam sodium 9
piperacillin sodium/tazobactam sodium 9
piperacillin/tazobactam 9
pirmella 1/35 51
pirmella 7/7/7 51
piroxicam 2
PLENAMINE 78
podofilox 39
poly vitamin 90
polycin 7
polyethylene glycol 3350 44
POLY-HIST DM 69
POLY-HIST PD 63
120
Drug Name Page #
poly-iron 150 78
polymyxin b sulfate 7
polymyxin b sulfate/trimethoprim sulfate 7
polysacc iron 150 complex 78
poly-vent dm 69
poly-vent ir 69
poly-vita drops 90
poly-vita/iron drops 90
polyvitamin 90
polyvitamin/iron 90
POMALYST 19
portia-28 51
PORTRAZZA 20
potassium chloride 78
potassium chloride 0.15% /nacl 0.45%
viaflex
78
potassium chloride 0.15% d5w/nacl 0.33% 78
potassium chloride 0.15% d5w/nacl 0.45% 78
potassium chloride 0.15% d5w/nacl 0.45%
viaflex
78
potassium chloride 0.15% w/nacl 0.9%
viaflex
78
potassium chloride 0.15%/d5w 78
potassium chloride 0.15%/nacl 0.9% 78
potassium chloride 0.22% d5w/nacl 0.45% 78
potassium chloride 0.224%/d5w/nacl 0.45% 78
potassium chloride 0.3%/ nacl 0.9% 78
potassium chloride 0.3%/d5w 78
potassium chloride 0.3%/nacl 0.9%/viaflex 78
potassium chloride cr 78
potassium chloride er 78
potassium chloride sr 78
potassium citrate er 78
POTIGA 11
povidone-iodine 7
PRADAXA 31
pramipexole dihydrochloride 23
pramipexole dihydrochloride er 23
pravastatin sodium 36
prazosin hcl 33
PRED MILD 61
PRED-G 61
PRED-G S.O.P. 61
prednicarbate 47
prednisolone 47
prednisolone acetate 61
prednisolone sodium phosphate 47
Drug Name Page #
prednisolone sodium phosphate 61
prednisone 47
prednisone intensol 47
PREGNYL W/DILUENT BENZYL
ALCOHOL/NACL
48
PREMARIN 51
PREMASOL 78
premium blood glucose test strips 59
premium lidocaine 5
prevalite 37
prevent 90
previfem 51
PREZCOBIX 28
PREZISTA 28
PRIMAQUINE PHOSPHATE 23
primidone 12
PRIMSOL 7
PRISTIQ 14
PRIVIGEN 55
pro comfort lancets 30g 59
PROAIR HFA 65
PROAIR RESPICLICK 65
probarimin qt 78
probenecid 17
probenecid/colchicine 17
PROCALAMINE 78
prochlorperazine 24
prochlorperazine edisylate 24
prochlorperazine maleate 24
PROCRIT 32
procto-med hc 47
procto-pak 47
proctosol hc 47
proctozone-hc 47
prodigy safety lancets 59
profe 78
proferrin es 78
progesterone 52
PROGLYCEM 30
PROGRAF 55
PROLASTIN-C 69
PROLEUKIN 20
PROLIA 57
PROMACTA 32
promethazine hcl 15
promethazine hcl plain 15
promethazine vc/codeine 69
121
Drug Name Page #
promethazine/codeine 63
promethazine/codeine 69
promethazine/dextromethorphan 69
promethazine-dm 69
propafenone hcl 34
propafenone hcl er 34
propantheline bromide 41
proparacaine hcl 60
propranolol hcl 34
propranolol hcl er 34
propranolol/hydrochlorothiazide 34
propylthiouracil 54
PROQUAD 56
PROSOL 78
protectiron 90
protexin 90
protriptyline hcl 15
PRUDOXIN 40
pseudoephedrine hcl 69
PULMOZYME 65
puralube 60
pure c 500 90
pureway-c 90
PURIXAN 19
pyrazinamide 18
pyridostigmine bromide 17
pyridostigmine bromide er 17
pyridoxine hcl 90
qc anti-diarrheal 43
qc arthritis pain relief 1
qc calcium fast dissolution 78
qc calcium/minerals/vitamin d 90
qc childrens chewable vitamins/extra c 90
qc cough/sore throat nighttime 69
qc ibuprofen 2
qc loratadine allergy relief 63
qc loratadine-d 63
qc maximum daily
multivitamin/multimineral
90
qc multi-vite 90
qc naproxen sodium 2
qc tolnaftate 17
qc unilet lancets 33g/micro thin 59
qc womens daily multivitamin 90
q-dryl 63
q-pap 1
q-pap childrens 1
Drug Name Page #
q-pap extra strength 1
q-pap infants 1
q-tussin 69
q-tussin dm 69
QUADRACEL 56
quasense 51
quenalin 63
quetiapine fumarate 25
quinapril hcl 33
quinapril/hydrochlorothiazide 33
quinidine sulfate 34
quinine sulfate 23
quintabs-m 90
QVAR 62
ra balanced b-100 90
ra balanced b-50 90
ra b-complex 90
ra b-complex with b-12 90
ra b-complex/vitamin c tr 90
ra beta carotene 90
ra biotin 90
ra calcium 600 79
ra calcium 600 plus vitamin d-3 90
ra calcium 600/vit d/minerals 79
ra calcium citrate plus vitamin d-3 79
ra calcium soft chews 90
ra calcium/boron 91
ra calcium/magnesium/zinc/copper 91
ra central-vite 91
ra central-vite cardio 79
ra central-vite energy 91
ra central-vite performance 79
ra central-vite select mature 91
ra central-vite senior 91
ra central-vite under 50 mens 79
ra central-vite under 50 womens 79
ra central-vite womens mature 79
ra central-vite/antioxidants 91
ra coral calcium 91
ra hi cal 91
ra hi-cal plus vitamin d 91
ra high potency iron 91
ra iron 91
ra magnesium 91
ra natural magnesium 79
ra natural vitamin e 91
ra niacin 91
122
Drug Name Page #
ra one daily energy formula 91
ra one daily essential 91
ra one daily maximum 91
ra one daily mens 50+ with vitamin d-3 91
ra one daily multi-vitamin 91
ra one daily multi-vitamin plus iron 91
ra oyster shell calcium/vitamin d 91
ra pediatric electrolyte 79
ra pediatric electrolyte freezer pops 79
ra selenium 79
ra selenium natural 79
ra slow release iron 79
ra stress formula advanced 91
ra stress formula energy 91
ra therapeutic m plus beta carotene 91
ra vitamin a 91
ra vitamin b-1 91
ra vitamin b12 91
ra vitamin b-12 91
ra vitamin b-12 tr 91
ra vitamin b-6 91
ra vitamin c 91
ra vitamin c drops 91
ra vitamin c tr 91
ra vitamin c/acerola 91
ra vitamin c/rose hips 91
ra vitamin c/rose hips tr 91
ra vitamin e 92
ra whole source complete formula for men 92
ra whole source dietary 92
ra whole source dietary for men 92
ra whole source dietary mature 92
ra zinc 79
rabano yodado 92
RABAVERT 56
raloxifene hydrochloride 52
ramipril 33
RANEXA 35
ranitidine 150 maximum strength 43
ranitidine 75 43
ranitidine hcl 43
ranitidine maximum strength 44
RAPAMUNE 55
REBETOL 27
REBIF 38
REBIF REBIDOSE 38
REBIF REBIDOSE TITRATION PACK 38
Drug Name Page #
REBIF TITRATION PACK 38
reclipsen 51
RECOMBIVAX HB 56
REFRESH CELLUVISC 60
REFRESH LACRI-LUBE 60
REFRESH PLUS 60
REGONOL 17
REGRANEX 40
reguloid 43
relion prime blood glucose test strips 59
RELISTOR 43
REMICADE 55
REMODULIN 65
renal vitamin 92
renal-vite 92
rena-vite 92
RENVELA 46
repaglinide 30
REPATHA 37
REPATHA PUSHTRONEX SYSTEM 37
REPATHA SURECLICK 37
reprexain 4
RESCON 64
RESCON DM 69
RESCON-GG 69
RESCRIPTOR 27
RESPAIRE-30 69
RESTASIS 60
restfully sleep 64
RETROVIR IV INFUSION 28
REVLIMID 19
REXULTI 25
REYATAZ 28
REZIRA 69
ribasphere 27
RIBASPHERE RIBAPAK 27
RIBATAB 27
ribavirin 27
RIDAURA 55
rifabutin 18
rifampin 18
RIFATER 18
riluzole 38
rimantadine hcl 28
RINGERS INJECTION 79
RINGERS IRRIGATION 59
RIOMET 30
123
Drug Name Page #
risacal-d 92
risedronate sodium 57
RISPERDAL CONSTA 25
risperidone 25
risperidone m-tab 25
risperidone odt 25
RITUXAN 22
rivastigmine tartrate 13
rivastigmine transdermal system 13
rizatriptan benzoate 17
rizatriptan benzoate odt 17
robafen 69
robafen cf cough & cold 69
robafen cf multi-symptom cold 69
robafen cough 69
robafen dm 69
robafen dm cough clear 69
ropinirole hcl 23
rosadan 7
rosuvastatin calcium 37
ROTARIX 56
ROTATEQ 56
roweepra 11
roxicet 4
ROZEREM 70
ru-hist d 64
rulox 43
rymed 64
rynex dm 69
rynex pe 64
rynex pse 64
S2 65
SABRIL 12
SAIZEN 48
SAIZEN CLICK.EASY 48
salsalate 3
SAMSCA 70
SANDIMMUNE 55
SANDOSTATIN LAR DEPOT 53
sani-supp adult 44
sani-supp pediatric 44
SANTYL 40
SAPHRIS 25
sb pediatric electrolyte 79
scooby-doo one a day 92
selegiline hcl 24
selenium 79
Drug Name Page #
selenium sulfide 40
SELZENTRY 28
senexon 43
senior tabs 92
senna 43
senna 44
senna lax 43
senna plus 44
senna-lax 44
sennalax-s 44
SENSIPAR 53
sentry 92
sentry senior 92
SEREVENT DISKUS 65
SEROQUEL XR 25
sertraline hcl 14
se-tan plus 79
setlakin 51
sharobel 52
siderol 92
sidestream pediatric facemask 59
sidestream pediatric facemask/tucker the
turtle
59
SIGNIFOR 53
siladryl allergy 64
sildenafil 65
SILENOR 70
silicone mask for breatherite
chamber/pediatric
59
silphen cough 64
siltussin dm das 69
siltussin sa 69
siltussin-dm 69
silver sulfadiazine 7
SIMBRINZA 61
simethicone 43
SIMULECT 55
simvastatin 37
sirolimus 55
SIRTURO 18
slo-niacin 92
slow fe 79
slow release iron 79
slow-mag 79
sm allergy 4 hour 64
sm allergy relief 64
sm antacid anti-gas 43
124
Drug Name Page #
sm antacid/antigas 43
sm anti-diarrheal 43
sm balanced b-50 79
sm calcium 500/vitamin d3 79
sm calcium 600/vitamin d 79
sm calcium citrate w/vitamin d3 79
sm calcium soft chews 79
sm calcium/magnesium/zinc 79
sm calcium/vitamin d 79
sm chewable c 92
sm complete 79
sm complete advanced formula 79
sm complete senior formula 79
sm ibuprofen 3
sm iron 79
sm loratadine 64
sm lorata-dine d 64
sm magnesium 79
sm miconazole 7 17
sm multiple vitamins essential 79
sm multiple vitamins/iron 79
sm nasal decongestant maximum strength 69
sm nasal spray 12 hour 69
sm oyster shell calcium/vitamin d 79
sm oyster shell calcium/vitamin d3 79
sm pediatric electrolyte 80
sm selenium 80
sm sleep aid 64
sm slow release iron 80
sm super b complex-vitamin c 92
sm tussin 69
sm tussin dm 69
sm tussin dm cough/chest congestion 69
sm vit c/rose hips 80
sm vitamin b-12 80
sm vitamin b-6 80
sm vitamin c 80
sm vitamin c/rose hips 92
sm vitamin e 80
sm vitamin e blended 80
sm zinc 80
sodium bicarbonate 43
sodium bicarbonate 70
sodium bicarbonate partial fill 70
sodium chloride 60
SODIUM CHLORIDE 80
SODIUM CHLORIDE 0.45% 80
Drug Name Page #
SODIUM CHLORIDE 0.9% 59
SODIUM EDECRIN 36
sodium fluoride 80
SODIUM LACTATE 70
sodium phenylbutyrate 41
sodium polystyrene sulfonate 71
sodium sulfacetamide 10
SOLTAMOX 19
SOLU-CORTEF 47
SOMATULINE DEPOT 53
SOMAVERT 53
sore throat & cough lozenges 5
sorine 34
sotalol hcl 34
sotalol hcl (af) 34
SOVALDI 27
SPIRIVA HANDIHALER 64
SPIRIVA RESPIMAT 64
spironolactone 36
spironolactone/hydrochlorothiazide 36
SPORANOX 17
sprintec 28 51
SPRITAM 11
SPRYCEL 22
sps 71
sronyx 51
SSD 7
stahist ad 69
stavudine 28
sterile water irrigation 59
STIMATE 48
stimulant laxative 43
STIOLTO RESPIMAT 69
STIVARGA 22
stool softener 43
stool softener 45
stool softener extra strength 43
stool softener laxative dc 43
STRATTERA 38
streptomycin sulfate 6
stress b/zinc 92
stress formula 92
stress formula w/iron 92
stress formula/iron 92
stress formula/zinc 92
STRIBILD 27
STRIVERDI RESPIMAT 65
125
Drug Name Page #
strovite forte 92
strovite one 92
SUBOXONE 5
sucralfate 45
sudogest 69
sudogest 12 hour 69
sudogest pe 69
sudogest sinus & allergy 64
sulfacetamide sodium 10
sulfacetamide sodium/prednisolone sodium
phosphate
10
sulfadiazine 10
sulfamethoxazole/trimethoprim 10
sulfamethoxazole/trimethoprim ds 10
sulfasalazine 57
sulfatrim pediatric 10
sulindac 3
sumatriptan 17
sumatriptan succinate 17
sumatriptan succinate refill 17
super b complex maxi 92
super b complex/c 92
super b with c 93
super biotin 93
super calcium 80
super calcium 600 + d3 80
super calcium 600+d 400 80
super calcium 600+d3 400 80
super quints b-50 93
super thera vite m 93
superplex-t 93
supervite ec 93
suplevit 93
support 80
support-500 93
SUPRAX 8
SUPREP BOWEL PREP 45
SURMONTIL 15
suspendol-s 59
SUSTIVA 27
SUTENT 22
SYLATRON 20
symax-sl 41
SYMBICORT 62
SYMLINPEN 120 30
SYMLINPEN 60 30
SYNAGIS 55
Drug Name Page #
SYNAREL 53
SYNERCID 7
SYNRIBO 20
SYNTHROID 52
SYPRINE 71
tab-a-vite 93
tab-a-vite maximum 93
tab-a-vite w/beta carotene 93
tab-a-vite womens 93
tab-a-vite/iron 93
TABLOID 19
tacrolimus 40
tacrolimus 55
TAFINLAR 22
TAGRISSO 22
TALWIN 4
TAMIFLU 29
tamoxifen citrate 19
tamsulosin hcl 45
TANDEM 80
tandem plus 80
TARCEVA 22
TARGRETIN 22
tarina fe 1/20 51
taron forte 80
TASIGNA 22
tazicef 8
TAZORAC 40
taztia xt 35
TECENTRIQ 22
TEFLARO 8
TEGRETOL-XR 12
TEKTURNA 35
TEKTURNA HCT 35
telmisartan 33
telmisartan/amlodipine 33
telmisartan/hydrochlorothiazide 33
temazepam 70
TENIVAC 56
terazosin hcl 45
terbinafine hcl 17
terbutaline sulfate 65
terconazole 17
TESTIM 48
testosterone 48
testosterone cypionate 48
testosterone enanthate 48
126
Drug Name Page #
testosterone pump 48
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
56
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED ADULT
56
tetrabenazine 38
tetracycline hcl 11
TEXACORT 47
th antacid regular strength 43
th b 100 complex 93
th b complex/iron/vitamin c/vitamin e 93
th calcium 80
th calcium 600 with vitamin d 80
th calcium 600/vitamin d 80
th calcium citrate/vitamin d 80
th complete multi 93
th complete multi 50+ 93
th daily multiple vitamins 93
th daily multiple vitamins/iron 93
th iron 80
th oyster shell calcium/vitamin d 80
th premium daily multiple 93
th theradex-m 93
th vitamin b 50/b-complex 93
th vitamin b1 93
th vitamin b12 93
th vitamin b-12 93
th vitamin b12 er 93
th vitamin b-6 93
th vitamin c 93
th vitamin c/rose hips/bioflavonoids 93
th vitamin e 93
th vitamin e/d-alpha 93
th zinc 80
THALOMID 19
THEO-24 65
theochron 65
theophylline cr 65
theophylline er 65
thera 94
thera m plus 93
thera/beta-carotene 94
THERA-GESIC 40
thera-m 94
therapeutic liquid 80
thera-tabs 94
theratrum complete 80
Drug Name Page #
theratrum complete 94
therems 94
therems-h 94
therems-m 94
thiamine hcl 94
thioridazine hcl 24
thiotepa 18
thiothixene 24
THYMOGLOBULIN 55
THYROLAR-1 52
THYROLAR-1/2 52
THYROLAR-1/4 52
THYROLAR-2 52
THYROLAR-3 53
thyrosafe 59
thyroshield 59
tiagabine hydrochloride 12
TIKOSYN 34
tilia fe 51
TIMENTIN 9
timolol maleate 34
timolol maleate 61
tioconazole-1 17
TIVICAY 27
tizanidine hcl 26
TOBI PODHALER 65
TOBRADEX 61
tobramycin 65
tobramycin sulfate 6
tobramycin/dexamethasone 61
TOBREX 6
tolcapone 23
tolmetin sodium 3
tolnaftate 17
tolterodine tartrate 45
topiramate 12
toposar 21
topotecan hcl 21
TORISEL 55
torsemide 36
total b/c 94
totalday multiple 80
TOUJEO SOLOSTAR 31
TPN ELECTROLYTES 80
TRACLEER 65
TRADJENTA 30
tramadol hcl 4
127
Drug Name Page #
tramadol hcl er 3
tramadol hydrochloride/acetaminophen 4
trandolapril 33
tranexamic acid 32
TRANSDERM-SCOP 15
tranylcypromine sulfate 14
TRAVASOL 80
TRAVATAN Z 59
travel sickness 15
trazodone hcl 13
TREANDA 18
TRECATOR 18
TRELSTAR 53
TRELSTAR MIXJECT 53
TRESIBA FLEXTOUCH 31
tretinoin 22
tretinoin 40
tretinoin microsphere 40
tretinoin microsphere pump 40
trezix 4
triamcinolone acetonide 39
triamcinolone acetonide 47
triamcinolone acetonide 62
triamcinolone in orabase 39
triamterene/hydrochlorothiazide 36
trianex 48
triderm 48
tri-estarylla 51
trifluoperazine hcl 24
trifluridine 29
trihexyphenidyl hcl 23
tri-legest fe 51
tri-linyah 51
trilyte 45
trimethoprim 7
trimethoprim sulfate/polymyxin b sulfate 7
trimipramine maleate 15
TRINTELLIX 13
triple antibiotic 7
triple antibiotic plus 7
tri-previfem 51
TRISENOX 20
tri-sprintec 51
TRIUMEQ 28
tri-vi-sol 94
tri-vita 94
tri-vitamin 94
Drug Name Page #
trivora-28 51
trixaicin 40
trixaicin hp 40
TROKENDI XR 12
TROPHAMINE 80
tropicamide 60
true metrix self monitoring blood glucose
strips
59
TRULICITY 30
TRUMENBA 56
TRUVADA 28
tussin dm 69
tussin dm clear 69
TUSSIONEX PENNKINETIC
EXTENDED RELEASE
69
TWINRIX 56
TYBOST 28
TYGACIL 7
TYKERB 22
TYPHIM VI 56
TYSABRI 38
TYZEKA 26
TYZINE PEDIATRIC NASAL DROPS 69
ULORIC 17
unicomplex-m 94
unilet lancets micro-thin33g 59
UNITHROID 53
UNITUXIN 22
ursodiol 43
UVADEX 40
VAGIFEM 51
valacyclovir hcl 29
VALCHLOR 18
VALCYTE 26
valganciclovir 26
valganciclovir hydrochlorde 26
valproate sodium 12
valproic acid 12
valsartan 33
valsartan/hydrochlorothiazide 33
VANACOF 69
VANACOF DM 70
VANACOF-8 70
VANAHIST PD 64
vancomycin 7
vancomycin hcl 8
vancomycin hcl in dextrose 8
128
Drug Name Page #
vandazole 8
VAQTA 56
VARIVAX 56
VARIZIG 56
VASCEPA 37
v-c forte 94
VECTIBIX 22
VECTICAL 40
VELCADE 20
velivet 51
VELPHORO 46
VENCLEXTA 20
VENCLEXTA STARTING PACK 20
venlafaxine hcl 14
venlafaxine hcl er 14
verapamil hcl 35
verapamil hcl er 35
verapamil hcl sr 35
VERSACLOZ 26
VESICARE 45
vic-forte 94
vicodin 4
vicodin es 4
vicodin hp 4
VICTOZA 30
VIDEX PEDIATRIC 28
vienva 51
VIGAMOX 10
VIIBRYD 14
VIIBRYD STARTER PACK 14
VIMPAT 12
vinblastine sulfate 20
vincasar pfs 20
vincristine sulfate 21
vinorelbine tartrate 21
viorele 51
VIRACEPT 28
VIRAMUNE XR 27
VIRAZOLE 70
virdec 64
virdec dm 70
VIREAD 28
virt-phos 250 neutral 80
virtussin a/c 70
vita-bee/c 94
vitalee 94
vitalets 94
Drug Name Page #
vitalets childrens 94
vitamin a 94
vitamin a & d 40
vitamin b 6 94
vitamin b complex 95
vitamin b complex-c 95
vitamin b1 95
vitamin b-1 95
vitamin b12 95
vitamin b-12 95
vitamin b-12 tr 95
vitamin b-2 95
vitamin b-6 95
vitamin b-complex 95
vitamin c 95
vitamin c sr 95
vitamin c tr 95
vitamin c tr/rose hips 95
vitamin c/rose hips 95
vitamin d 95
vitamin e 95
vitamin e water dispersible 95
vitamin e water soluble 95
vitamin e/d-alpha 95
vitamin e/d-alpha natural 95
vitamin e-400 95
vitamin k1 95
vitamins & minerals 95
vitamins for hair 95
vitatrum 95
VITEKTA 27
vitrum 50+ senior multi 95
VOLTAREN 40
voriconazole 17
VOTRIENT 22
VP-PNV-DHA 95
VPRIV 41
VRAYLAR 25
vyfemla 51
warfarin sodium 31
wee care 80
WELCHOL 37
wera 51
white petrolatum 40
womens biomultiple 95
womens daily formula 95
129
Drug Name Page #
womens daily formula/folic
acid/calcium/iron
95
womens one daily 95
XALKORI 22
XARELTO 32
XARELTO STARTER PACK 32
XARTEMIS XR 3
XENAZINE 38
XGEVA 57
XIFAXAN 8
XOLAIR 70
XTANDI 18
xylon 4
XYREM 70
yelets teenage formula 95
YERVOY 22
YF-VAX 56
YONDELIS 18
zafirlukast 64
zaleplon 70
ZALTRAP 22
ZANOSAR 18
ZARXIO 32
ZAVESCA 41
ZEASORB-AF 17
zebutal 1
ZELBORAF 22
ZEMAIRA 70
zenatane 40
zenchent 51
ZENPEP 41
ZETIA 37
ZIAGEN 28
zidovudine 28
zinc 70
zinc 81
zinc 15 80
zinc chelated 81
zinc gluconate 81
zinc oxide 40
zinc sulfate 81
zinc/vitamin c 59
zinc-220 81
ZIOPTAN 59
ziprasidone hcl 25
ZIRGAN 26
ZMAX 10
Drug Name Page #
zoledronic acid 57
ZOLINZA 21
zolpidem tartrate 70
ZONALON 40
ZONATUSS 70
zonisamide 11
zoo friends 95
zoo friends plus iron 95
ZORTRESS 55
ZOSTAVAX 56
ZOSYN 9
zovia 1/35e 52
zovia 1/50e 52
ZOVIRAX 29
ZUTRIPRO 70
ZYCLARA 40
ZYCLARA PUMP 40
ZYDELIG 21
ZYKADIA 22
ZYLET 6
ZYPREXA RELPREVV 26
ZYTIGA 18
ZYVOX 8